Care Coordinator - Waterloo, Canada - Home and Community Care Support Services

Home and Community Care Support Services

Verified Company

Waterloo, Canada

2 weeks ago

Posted by:

Sophia Lee

beBee Recruiter

Description

Job Description:

Care Coordinator - Complex Vulnerable, with a focus on Newcomer Health:

REPORTS TO:
Patient Services Manager

LOCATION:
Home and Community Care Support Services Waterloo Wellington

OFFICE BASE:
Waterloo

STATUS:
Permanent, Full-Time

SCHEDULE:7 hours/day, prescheduled Monday-Sunday

UNION:

ONA

ASSIGNMENT:1.0 FTE

POSTING #:23-O-038

POSTING DATE:
February 24, 2023

CLOSING DATE:
March 3, 2023, 4:30 pm

***:
***: To act as an organizational lead within Home and Community Care Support Services Waterloo Wellington for all newcomer health and complex vulnerable needs. Main areas of focus will involve supporting newcomer (including refugee) and complex vulnerable populations in accessing community resources and obtaining meaningful primary attachment within Home and Community Care Support Services.

While ensuring a health equity focus, this position will be responsible for supporting complex vulnerable and newcomer patients by completing comprehensive assessments to inform integrated care and transition plans for patients across Home and Community Care Support Services.

Working closely with local Primary Health Care providers as well as other community partners, this position will be integral in ensuring newcomers and complex vulnerable residents including Indigenous residents are receiving the right care at the right time

KEY RESPONSIBILITIES:

Reporting to the Manager of Patient Services, the incumbent will be responsible for:

Engaging in health system improvement by participating in research, quality improvement initiatives, systems projects and pilots that support the development and integration within the Ontario health care system (i.e. KW4 Ontario Health Team working groups)
Act as an organizational lead and resource for staff regarding language interpretation services
Participating in evidenced based program development & engaging in continuous professional development
Engaging the patient by establishing a committed relationship; to work with the patient in addressing their needs and goals
Assessment of referred patients to obtain information in order to identify a patient's functional and cognitive status, strengths, values, abilities, preferences, resources, supports and need
Determination of eligibility for services or programs based on legislation, standards, regulations; policies and funding options, this may include supporting patients in accessing and implementing services funded through alternate sources (ie. Interim Federal Health Program IFHP)
Developing individual patientcentred coordinated care plans in collaboration with patient/Substitute Decision Maker and with other providers to address newcomer health needs by utilizing information from the assessment, legislation, standards, regulations and policies
Implementation of the care plan, including monitoring and evaluation to ensure that the goals of the care plan are achieved
Reassessment of patients' needs and evaluation of the level of goal achievement related to the care plan
Planning for discharge once the identified goals and outcomes have been achieved
Supporting meaningful longterm attachment through facilitating transitions from initial primary newcomer health care providers to other primary care providers throughout the Home and Community Care Support Services Waterloo Wellington geography
Serving as primary contact, advocate, and system resource for newcomer patients
Integrates cultural sensitivity and humility throughout performance of this role
Supporting and develop patients' independence in navigating the Ontario health care system through culturally and linguistically appropriate orientation
Demonstrating an awareness of diverse conceptualizations of health and wellness and providing health literacy education as appropriate
Connecting patients to relevant community resources with the goal of enhancing patient health and wellbeing, increasing patient satisfaction, and reducing health care costs
Promoting and build capacity for integrated care and transition plans for complex vulnerable patients across Home and Community Care Support Services.
Maintaining confidentiality of patient records;
Documenting on different electronic platforms (i.e. CHRIS & PS Suites etc.) according to Home and Community Care Support Services and professional college standards of documentation
Working in a multidisciplinary team (Integrated Care Teams (ICT)) with community partners that promote positive working relationships, working in partnership with Centre for Family Medicine, Reception House, Sanctuary Refugee Health Centre/KDCHC and other partners
Taking all reasonable steps to ensure a healthy and safe work environment and participates in continuous quality improvement
Travel throughout the entire Waterloo Wellington geographic area is required
Performing other duties as required.