Clinical Care Coordinator

Job Description

Are you an experienced registered nurse, seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

As a Clinical Care Coordinator, you will support a population of patients with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) who are admitted to hospital or present in the Emergency Department. These more complex, chronic patients are often discharged home with a limited level of support as they transition back to the community.

The Clinical Care Coordinator will effectively engage and collaborate with hospital, primary and community care partners to:

1. Provide clinical assessment and direct care intervention to patients with mild to moderate COPD / CHF to discharge home and maintain support.
2. Inform and support the care coordinator in developing the patient’s care plan.
3. Use best evidence available to support the patient towards increased self-management and maintenance at home to avoid future ER visits/hospitalizations (post-hospital home clinic for up to 60 days).

As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work-life balance.

This is a permanent full-time position in our London location.

What will you do?

1. Complete clinical intake assessment in the home and develop a clinical care plan upon admission and project a discharge/transition plan for the patient to effectively manage their health.
2. Progress the patient through the clinical care pathways in partnership with the Home Care Team.
3. Collaborate in creating the discharge/transition plan including progression to self-management.
4. Receive, prioritize and take timely action regarding new referrals, identifying and connecting with patients and their circle of care (hospital, primary care, community) to develop and build.
5. Gather initial and ongoing information using standardized assessment tools to support the patient to be discharged home in a safe and timely manner.
6. Make referrals to a wide variety of community supports and assist patients and their families through the process.

What must you have?

1. Membership, in good standing, with the College of Nurses of Ontario.
2. 5+ years of relevant experience as a Registered Nurse (BScN or diploma) preferably with ICU, ED, Medicine, Respirology and/or Cardiology experience.
3. Current clinical experience or clinical experience within the last three (3) to six (6) months.
4. Clinical expertise in COPD/CHF care.
5. Knowledge of the health care delivery system and community resources.
6. Excellent interpersonal, communication, assessment, problem-solving, and decision-making skills.
7. Effective time management, prioritization and organizational skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment.
8. Established ability to accurately complete required documentation, reports and forms.
9. A valid driver’s licence and access to a reliable vehicle.
10. Proficient in a Windows environment.
11. We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

1. Completion of a COPD/CHF Educator Program.
2. Ability to speak French or another second language.

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer:

1. Attractive comprehensive compensation packages and benefits.
2. Valuable development opportunities.
3. Membership in a world-class defined benefit pension plan.

Who we are

We are Ontario Health at Home, ready to serve every person in Ontario. We partner with patients and caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred care.

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Ontario Health at Home is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.