Care Coordinator - (Durham OHT LP)

Overview

Care Coordinator - (Durham OHT LP) role at Ontario Health atHome .

Date Posted: September 17, 2025

Closing Date: September 24, 2025

Job Type: Full-time

Start Date: October 5, 2025

Program: All Patient Service Programs

Branch: Whitby

Group: ONA

Ontario Health (OH), working in partnership with the Ministry of Health (MOH) and Ontario Health atHome (OH atHome), is engaging 7 Ontario Health Teams (OHTs) to advance Home Care Modernization Leading Projects. This will be a targeted phase of innovation and learning that will inform provincial planning related to home care modernization, along with a review of other care models and other MOH modernization initiatives. The goal of these Leading Projects (LPs) is to advance the integration of home care delivery in OHTs and the modernization of home care delivery at scale in alignment with the end-state vision.

The Objectives Of These LPs

• Contribute to advancing the quintuple aim in home care, including improved responsiveness to client needs, quality, access, equity of care for clients/patients and caregivers, and improved provider experience.
• Build on the development of new models of home care delivery, apply local and international best practices, and leverage lessons learned from prior tests of change.
• Demonstrate potential for new models of care that can/will be enabled by the ministry’s new legislation and that are connected to broader OHT services, including primary care.
• Inform future transformation of the home care sector through a focused, collaborative approach that prioritizes learning and continuous improvement and builds a strong foundation for transition.
• Expand understanding of home care delivery by OHT partners, including care coordination roles and responsibilities.
• Share learnings that will help all parts of the province plan for home care modernization in future phases.

The LPs will enhance existing available home care services and will not negatively disrupt existing services, programs, or workforce.

Role purpose: This position is responsible for collaborating with patients and their families 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 (CC) may connect patients to additional resources and supports in the broader system, as part of developing a robust coordinated care plan.

The purpose is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preferences of care. CCs will collaborate with patients, hospitals, primary care providers, service provider organizations, and community supports 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 CC assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an interdisciplinary team, and reviews patients’ care plans as required to ensure needs are met to achieve goals of care. CCs will also follow OH atHome policies and LP OHT policies, procedures and parameters relating to delivery of care coordination functions including mandatory consultation, communication and collaboration with the integrated care team. CCs report to an OH atHome Patient Services Manager and are accountable to the LP OHT for advancing integrated, team-based care. With shared accountability between OH atHome and the OHT, CCs connected with an LP will work as part of an integrated care team to carry out care coordination functions.

Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

Durham OHT LP Details: OH atHome CCs, as part of the One Care Team, will participate in Team Huddles and will be responsible for initial assessment (interRAI) as directed. They will ensure comprehensive system navigation and work with the One Care Team to identify patient risks and maintain care needs and goals.

What will you do?

CCs Will Be Responsible For:

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

Responsibilities

CCs will also be responsible for working with staff of health service providers (HSPs) and service provider organizations (SPOs), who may also be responsible for:

• Revising care plans (e.g., number of visits, types of services) within the approved model of care and written arrangements between LP HSP and the performing organization;
• Carrying out additional clinical assessments to inform care planning, including by the OH atHome CC;
• Assessing/reassessing patient needs for other health and social services offered by LP HSP (e.g., mental health, housing, community supports);
• Providing information about and referrals to other health and social service providers.

Qualifications

What must you have?

• Regulated health care professional (RHP) with current registration in Ontario in one of nursing (RN), physiotherapy, occupational therapy, medical social work, dietetics, or speech-language pathology;
• Appropriate university degree or suitable combination of education and direct experience;
• Eligibility to determine patient capacity under the Health Care Consent Act (1996);
• 1-3 years of experience in community health or related field;
• Minimum 2-3 years of relevant recent experience as a Regulated Health Professional in a clinical setting (e.g., hospital, physician office);
• Solid knowledge of the Ontario healthcare system, the role of CC as assessor and health planner, relevant legislation and local resources;
• Understanding of PHIPA and Home and Community Care Services Regulation under the Connecting Care Act, 2019;
• Strong communication, documentation, and computer skills (MS Office, internet navigation);
• Ability to analyze information, problem-solve and make decisions;
• Commitment to quality service, culturally safe and trauma-informed care;
• Ability to establish wide professional networks and maintain confidentiality.

What would give you the edge?

• Community nursing experience
• French or additional language skills

Hours Of Work

All hours of operation (initially Monday-Friday 08:30-16:30; 70 hours per bi-weekly pay period) subject to change per the Collective Agreement. Hybrid work model; travel within Ontario Health atHome Central East region may be required. A valid Ontario driver’s license and access to a vehicle are necessary.

What do we offer?

We Know Wellness Is Supported With Work-life Balance. In an inclusive culture committed to learning, growth and innovation, we offer:

• Attractive compensation and benefits
• Development opportunities
• Membership in a defined benefit pension plan
• Salary: $41.92–$51.91/hour

Who we are

Ontario Health atHome partners with patients, caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams to deliver responsive, accessible, integrated, patient-centered care.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Ontario Health atHome is committed to equity, inclusion, diversity and anti-racism. We welcome applications from all qualified applicants and provide accommodations for disabilities upon request during the recruitment process.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.

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