Clinical Care Coordinator

Job Responsibility: : 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 Heather 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 supprot as they transition back to the community. The Clinical Care Coordinator will effectively engage and collaborate with hospital, primary and community care partners to:

• Provide clinical assessment and direct care intervention to patients with mild to moderate COPD / CHF to discharge home and maintain support in the
• Inform and support the care coordinator developing the patient's care plan
• 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?

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

What must you have?

• Membership, in good standing, with the College of Nurses of Ontario
• Greater than three (3) years of relevant experience as a Registered Nurse (BScN or diploma) preferably with ICU, ED, Medicine, Respirology and/or Cardiology experience
• Current clinical experience or clinical experience within the last twelve (12) months
• Clinical expertise in COPD/CHF care
• Knowledge of the evolving role of Ontario Health atHome, and the issues and priorities within the health care sector and how these impact client service delivery
• Basic knowledge of Ontario Health atHome South West business strategies, objectives, priorities and programs, and related Client Services priorities and plans
• Practical knowledge of relevant legislation (e.g., Long Term Care Act, privacy legislation, )
• Effective planning, organizing and evaluation skills to manage multiple clients, provide information reports and take corrective action as required
• Must have a valid driver's license and access to a vehicle

What would give you the edge?

• Completion of a COPD/CHF Educator Program
• 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:

• Attractive comprehensive compensation packages and benefits
• Valuable development opportunities
Membership in a world class defined benefit pension plan

Who we are

We are Ontario Health atHome, 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 atHome 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 .