Job Description

Position:

Permanent Full-Time RN/RPN Care Coordinator

Job ID: CCH-2536

Bargaining Status: C.U.P.E. Local 4891

Hours of Work: Monday to Friday, 8:30am to 4:30pm

Service Area: Home Care and Community Support Services

Reports To: Director of Community Programs

Salary: $59,000.00 per annum

Start Date: As soon as possible

About CommunitiCare Health

We are a community health care agency that provides a full range of community health care and support services, making us a distinctive agency in Toronto offering a blend of community support services, community mental health and addictions services, supportive housing, inter-professional primary care and home care services. We are community governed. We continually look for ways to serve our clients and our community better and to provide enhanced access to equitable care. We are looking to expand our Primary Health Care team with the addition of a new Nurse Practitioner.

Position Summary

The Care Coordinator, under the direction of the Director, Community Programs is accountable and responsible for assessing client needs, determining eligibility of service, developing an appropriate plan of care and monitoring the care delivered. Drawing on your knowledge of health and social services, you will assist clients to navigate the health care system. You will work with clients to facilitate linkages with the right information and help them understand and manage their short-and long-term goals.

Key Responsibilities

Intake:

Respond to service inquires and provide appropriate information to potential clients, caregivers and other health care professionals; Receive referrals and conduct intake using appropriate tools; Determine client eligibility using appropriate criteria; Provide appropriate linkages, referrals as required; Maintain a waiting list when required.

Assessment/Reassessment:

Conduct initial assessments using interRAI-CHA assessment tool; Conduct an environmental safety check prior to initiation of service to ensure a safe work environment; Responsible for entry of client's detailed information in AlayaCare and maintaining client files; Complete reassessments as scheduled or as needed (i.e. change in client's conditions); Revise care plan as required (i.e. based on reassessment, change in medical conditions).

Care Plan and Coordination of Care:

Develop a care plan based on assessment and client's goals; Communicate with client and/or family members regarding the client's care plan; Communicate with Schedulers to ensure services are provided to clients according to the care plan; Monitor effectiveness of care plan by reviewing notes and communicating with program managers and schedulers; Respond to client issues/complaints regarding their care/services; Maintain client files up to date and keep a record of any incidents and issues that arise; Ensure notes are timely and clear, and contain appropriate and required information; Close client files upon discharge from Storefront Humber services; Work with other care providers to coordinate care when necessary; Attend case conferences with other providers within the circle of care; Serve as a point of contact and informational resources for client, family, care team, and community resource organizations; Respond and intervene appropriately to urgent situations of clients within their caseload or as referred by the internal managers, community providers, family, or client; Report any issues and concerns to the Director, Community Services; Work closely with program managers, schedulers and community resource organizations in coordinating client services; Ensure timely communication, inquiry and follow up.

Statistics and Records:

Working with the Managers, monitors monthly statistics; Ensure all statistical reports are prepared and submitted in a timely manner.

On Call Cell Phone:

Responsible to be on-call after regular business hours on a rotating schedule.

Other Requirements:

Attend staff meetings and training sessions as required; Maintain client confidentiality at all times; Work within a team concept to insure the quality, quantity and consistency of service delivery; and Other duties as assigned that are required by the agency for continuity of care

Qualifications

Registered Nurse (RN) / Registered Practical Nurse (RPN) with current CNO membership in good standing and able to work in the province of Ontario; 2-4 years' experience working in the Community Service sector or Home Health Care; Experience working with the senior at -risk population; Possess exceptional assessment and client consultative skills; Ability to prioritize and organize work; Familiar with InterRAI CHA assessment and it's link to care planning; Knowledge of direct care and case management models used in community healthcare organizations; Excellent customer service skills and ability to deal tactfully with clients, staff and community; and Computer skills and very good knowledge of other systems used in client service delivery (e.g. HPG, IAR, etc.)

Additional Requirements & Information

A driver's license and access to a personal vehicle that can be used for work purposes; A vulnerable Sector screening police records check; and Must be available for scheduled backup cell phone responsibility to provide immediate response to emergency issues.

Note to External Applicants

We thank all the applicants for their interest and advise that only those selected for an interview will be contacted.

As part of our hiring practices, we encourage and particularly welcome resumes from traditionally marginalized communities. This includes but is not limited to consumers/survivors, people of colour, indigenous peoples, persons with disabilities, and members of the 2SLGBTQI+ community.

If you have any requirements for accommodation due to disability, please advise Human Resources during the recruitment and selection process. We will work with you to best meet your needs as per the resources available to us.

CommunitiCare Health is a scent-free environment.

In an effort to keep our congregate housing settings as safe as possible, all new external candidates will be expected to provide proof of having received the COVID 19 vaccine.

Job Types: Full-time, Permanent

Pay: $59,000.00 per year

Licence/Certification:

RN/RPN license and able to work in Ontario (required) Driver's license and have access to a vehicle (required)
Work Location: In person