The Care Coordinator (CC) – Primary Care Partnership (PCP) will be embedded within primary care practice(s) and provide patient centered system navigation, intensive case management and coordination of services to patients and their primary care provider (including but not limited to Community Health Centre, Family Health Team, and other primary care models, including fee for service practices).
The CC will identify and facilitate access to the right services from the right provider at the right time by working collaboratively with primary care, inter-professional team members, family members, the patient’s support network, and a variety of informal and formal service providers. The CC acts as a key resource to patients, families, primary care physicians and partners regarding HNHB LHIN health, mental health and addictions, and community/social supports. The CC must have excellent communication and leadership skills such as; problem solving, critical thinking, negotiating and conflict resolution. The CC will be a passionate and patient focused clinician, and be able to build relationships with our community partners.
The CC will coordinate seamless care transitions and will be responsible for exchanging knowledge related to respective health conditions and the continuum of services and resources to enhance patient self-management and quality of care. The CC will ensure seamless transitions for the patient by acting as a liaison between patients and Community Support Services.
The CC will be responsible for ensuring cost effective patient care by utilizing resources efficiently and collecting necessary data on patient care to support the evaluation of outcomes of integrated care delivery.
French Language Services are required (Bilingual proficiency will be confirmed by a French Language Proficiency Assessment)
Core Duties - Responsibilities:
Identification and Engagement:
Engage and develop meaningful partnerships with the patient’s primary care provider(s);
With the patient’s primary care provider/team, responsible for reviewing patient’s care needs and assessing, planning, coordinating and implementing LHIN services by following Ministry of Health legislation and HNHB LHIN policies and procedures;
Providing information and referring patients to community resources;
To respond to inquiries and requests for service in accordance with the patient’s care needs, identified risk factors, and urgency for services;
To provide the patient with information about legislation, LHIN, patient rights and responsibilities, and services available;
To problem-solve inquires and issues with the patient’s needs and service provider’s need.
To obtain consent for the gathering and sharing of patient information;
To apply a health equity lens with a goal to address the root causes of health inequities and recognize the impact of social determinants of health.
Adopting a holistic and comprehensive approach, determine eligibility and assess for LHIN services as required;
Respect the patient’s privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences;
Facilitate information exchange across providers in multiple settings and sectors, in the support of creating the system-wide team where all health care providers contribute to the coordinated care plan;
Be responsible for planning and completing seamless transitions between services and providers
Determine capability and assess for placement into long term care facilities as required;
Counsel patient and family regarding the placement process; to understand the crisis component of urgent placement needs as required.
Accessing Resources and Linking:
Provide exceptional system navigation services and referral to appropriate LHIN Home & Community and community organizations to support the individual needs of patient;
Foster and sustain effective relationships with a broad group of system partners, including primary care in the advancement of the Health Links model of care;
Engage the patient & family and relevant health and social services stakeholders.
To develop a service plan that reflects the patient’s assessed needs across health, mental health and addictions, and community/social support continuum.
Collaborate with the patient to establish goals that reflect his or hers desired outcomes;
Complete and document Coordinated Care Plans in CHRIS;
Effectively partner with primary care providers to integrate subjective and objective information gathered during the comprehensive assessment and preplanning phase into the coordinated care planning process. The emphasis of this phase will incorporate the patient’s voice, while also providing for the validation, analyzing and interpreting of information gathered in the preparation for the creation of the coordinated care plan.
Service Implementation and Coordination:
To implement and monitor a coordinated service plan that reflects the patient’s needs and goals for service;
Initiate selected strategies to meet patient needs and ensure that services are provided and utilized as outlined in the coordinated care plan, including the initiation of new in-home and community-based services,
Ensure strategies and actions outlined in the coordinated care plan are initiated and reviewed at all transition points and upon change in patient condition
Ensure that information is shared across multiple settings and sectors to ensure all partners in care are contributing to the success of the coordinated care plan
Monitoring and Reassessment:
Monitor the outcome of the plan to ensure identified issues are escalated to Primary Care providers and others in the identified circle of care at regular intervals and as emerging issues arise;
To reassess for ongoing eligibility and continuing needs for service; to progress patients to independence when appropriate.
Resource Management and Fiscal Accountability:
To authorize the appropriate LHIN wide services to ensure the effective and efficient utilization of resources, in alignment with best practices and quality outcomes;
To problem solve with service providers to resolve discrepancies regarding billing with patient care plans.
To evaluate patient satisfaction with services, and to identify opportunities to improve the delivery of Local Health Integration Network services;
To identify trends that will impact LHIN wide resources;
To complete service feedback forms;
Play an instrumental role in reviewing the effectiveness of the care plan through the process of evaluation.
To maintain professional and LHIN documentation in accordance with professional documentation standards including the completion of appropriate forms;
To maintain accurate electronic patient files.
Other Related Tasks:
Collaborates with team members regarding coverage for patient care ;
Travel to support transitions in patient’s care within a catchment area and to meet operational needs;
Acts as a resource to other Home & Community staff to assist in orientation, implementing change, and problem solving;
Assists with projects and new initiatives as they relate to position;
Participates on committees;
Promotes Best Practices and implementation of Health Quality Ontario standards as appropriate;
Promotes and supports research initiatives;
Participates in relevant educational opportunities;
Other duties as assigned.
A University Degree. An equivalent of education and experience may be considered. Registered Nurses with a Diploma in Nursing shall receive equal consideration.
Practitioner in one of the following health disciplines: nursing, physiotherapy, occupational therapy, medical social work, dietetics, or speech-language pathology;
Maintain membership in a Regulated Health Professional College
Minimum two years recent experience in community health or a related field;
Knowledge of community resources;
French Language Services are required (Bilingual proficiency will be confirmed by a French Language Proficiency Assessment) for Francophone primary care settings.
Proven ability to build relationships and lead stakeholder engagement with First Nations, Inuit and Métis populations, cross-sector (hospital, long-term care, community, primary care).
Knowledge and ability to integrate holistic based and evidence based practice into planning and evaluation activities.
Knowledge of local First Nations, Métis and Inuit Peoples’ land, language, and history, as well as completion of training related to Indigenous Cultural Safety considered an asset.
Skills & Abilities:
Problem-solving and decision making skills;
Ability to prioritize and juggle multiple complex patient issues simultaneously
Interpersonal communication skills (written and verbal);
Knowledge of community resources is an asset;
Team building and collaboration;
Ability to work independently as well as in a team setting;
Collaboration with Internal and External stakeholders;
Organization, goal setting, planning, coordination and evaluation skills;
Computer experience and keyboarding skills on laptop and desktop computers;
Flexibility during transition.
Valid driver’s license;
Access to a motor vehicle – mandatory for community Care Coordination;
Driving to and from patient home visits, primary care setting(s) and other partners as required