Care Coordinator - Mississauga Ontario Health Team - Leading Project (M OHT)

Job Description - Ontario Health atHome (Mississauga Halton)

Are you an experienced registered nurse (BScN) seeking a rewarding career that cares for others in a professional practice that cares for you? Ontario Health atHome Mississauga Halton is seeking two qualified Registered Nurses to join the Mississauga Ontario Health Team, leading a Project on a Temporary Full-Time basis until November 29, 2026.

Position: Care Coordinator, Mississauga Ontario Health Team (M OHT)

The Care Coordinator is responsible for collaborating with patients and their families/caregivers to develop quality, timely and cost-effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes. The Care Coordinator may connect patients to additional resources and supports in the broader system to support a robust coordinated care plan.

The purpose of this position is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preferences for care. Care Coordinators will collaborate with patients, hospitals, primary care providers, service provider organizations, and community support service organizations to plan and deliver care and ensure patients are connected to other supports. In accordance with the Connecting Care Act, 2019 and its regulations, the Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an inter-disciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care. Care Coordinators will also carry out their duties in accordance with Ontario Health atHome policies and the Leading Project (LP) OHT’s policies, procedures and parameters relating to the delivery of Care Coordination functions, including mandatory points of consultation, communication and collaboration with the other members of the integrated care team.

Care Coordinators report to an Ontario Health atHome (OHaH) Patient Services Manager for employment-related matters and are accountable to the Leading Project OHT for advancing integrated, team-based care.

With shared accountability between OHaH and the OHT, and with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, Care Coordinators connected with an Ontario Health Team Leading Project.

The project will work as part of an integrated care team with OHT partners to carry out care coordination functions. As an integral member of the integrated care team, the Care Coordinator will contribute to the testing of home care models that improve integration, access, and patient outcomes and experience. Leveraging the key activities of care coordination, the OHT LP CC will help to inform potential scale and spread of new models of home care, including system processes and supports. Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

Mississauga OHT Leading Project Details:

In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

• Assess the health status of the patient, including but not limited to ESAS and PPS
• Initiate Goals of Care discussions and End of Life planning
• Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available
• Provide Pain and Symptom Management by being familiar with contents of the Symptom Management Kit and other prescribed medications
• Administer other medications as prescribed via the prescribed route
• Educate patient and family re: use of narcotic medication and other medications
• Initiate and monitor CAAD PCA Pump
• Complete a medication reconciliation (MedRec)
• Administer IV hydration as per medical orders, including IV start if required
• Educate & support patient and family with new IV/injectable meds & assess ongoing needs
• Complete Do Not Resuscitate (DNR) and Planned Death At Home (PDAH) form as appropriate
• Provide emotional and psycho-social support to the patient and family/caregivers
• Consult with MRP and Palliative care Nurse Practitioner as required
• Empty and maintain care of drains and catheters where applicable
• Provide patient care as per the patient’s care plan
• Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required
• Report any changes in health status to the MRP and Home and Community Care Support Services Palliative Care Coordinator
• Perform any additional tasks that may be asked of you to perform within the CNO (RN) scope of practice
• Potential for shift nursing on weekends if available

What will you do?

Care Coordinators will be responsible for:

• Assessing - and reassessing when appropriate - patient requirements, including mandatory interRAI assessments, but not including additional clinical assessments
• Making determinations of eligibility
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change
• Terminating the provision of a service

Care Coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:

• Revising care plans within the context of the approved model of care, and in accordance with written arrangements between the Leading Project HSP and the HSP or SPO performing these care coordination functions
• Carrying out additional clinical assessments to inform care planning
• Assessing/reassessing patient needs for other health and social services offered by the Leading Project HSP, such as mental health and addictions, housing, community supports
• Providing information about - and referrals to - providers of other health and social services

Care coordinator responsibilities will also include:

Identification and Engagement

• Engage and develop meaningful partnerships with health system partners involved in the patient’s care; follow policies and mandatory points of consultation, communication and collaboration with the integrated care team
• Respond to inquiries and requests for service in accordance with patient care needs
• Provide the patient with information about legislation, OHaH, LP OHT, Patient Bill of Rights and responsibilities under the Connecting Care Act, 2019
• Problem-solve inquiries and issues with the patient’s care plan execution
• Respect the patient’s privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences
• Obtain consent for the gathering and sharing of patient information
• Apply a health equity lens to address root causes of health inequities and social determinants of health

Patient Needs Assessments

• Facilitate needs assessment information exchange across providers to support an integrated care plan
• Determine capacity and placement into long term care facilities as required and counsel patient and family

Accessing Resources and Linking

• Provide system navigation and referrals to community organizations
• Engage patient & family and relevant health and social services stakeholders
• Plan for patient transition from hospital to community as required

Clinical Care

• Provide direct care responsibilities as defined by the Leading Project
• Pronouncement, DNR, Symptom Management

Community Relations

• Foster relationships with system partners, including primary care
• Engage with health care team members to build awareness of care coordination practice
• Demonstrate professional behaviours consistent with OHaH and LP OHT values
• Provide information about home and community care services to patients, families and providers

Care Planning and Coordination

• Monitor and coordinate delivery of services
• Establish care goals with the patient
• Ensure care plan actions are initiated and reviewed at transition points and with condition changes
• Share information across settings to ensure aligned care

Monitoring and Reassessment

• Monitor plan outcomes and escalate issues as needed
• Reassess ongoing eligibility and continuing needs

Resource Management and Fiscal Accountability

• Authorize home and community care delivery per plan and LP OHT policies
• Negotiate visit frequency and address billing with providers as needed

Documentation

• Maintain patient documentation in required systems (e.g., CHRIS, interRAI-PC, Clinical Connect)
• Document appropriately and maintain accurate electronic patient files

Other Related Tasks

• Collaborate within a team, cover patient care, support equity and inclusion, participate in committees, promote best practices, and support learning initiatives
• Travel throughout the OHaH geography as required
• Other duties as assigned

Patient Safety

• Promote patient safety and adhere to policies and procedures

What must you have?

• Registration in good standing with the College of Nurses of Ontario (RN)
• Minimum two years recent experience in community health or related field
• Palliative experience preferred
• Knowledge of Ontario health care system and care coordination
• PHIPA and regulatory knowledge; Home and Community Care Services Regulation under Connecting Care Act, 2019
• Knowledge of community health care strategies and models

Clinical Skills

• Strong clinical assessment and crisis management capabilities

Administrative and General Skills

• Policy adherence, MS Office proficiency, quality service focus, strong documentation
• Organizational, multitasking, adaptability and attention to detail

Communication & Interpersonal Skills

• Strong written and verbal communication; culturally safe and trauma-informed care
• Ability to collaborate with diverse professionals and language Skills a plus; valid driver’s license and reliable vehicle
• COVID-19 vaccination policy applies

What would give you the edge?

• Experience with diverse patient groups; case management or recent community experience; French or another language

What do we offer?

We support wellness through work-life balance and an inclusive culture with opportunities for growth. We offer:

• Attractive compensation packages and benefits
• Development opportunities
• Membership in a defined benefit pension plan

Who we are

Ontario Health atHome is ready to serve every person in Ontario. We partner with patients, caregivers, primary care providers, hospitals, long-term care, 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, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment: Ontario Health atHome is committed to equity, inclusion, diversity and anti-racism. Accommodations for disabilities are available upon request. We thank all applicants for their interest; however, only those selected for an interview will be contacted.