Continuing Care Coordinator - Continuing Care

The Care Coordinator is responsible for the assessment, care planning, authorization of services and the ongoing case management of clients referred to Continuing Care. Care coordinators help provide an array of services/programs offered by Nova Scotia Health Continuing Care and Department of Seniors and Long Term Care to assist individuals and families cope with complicated acute or chronic health situations in the most effective way possible in the community. Care Coordinators assist clients to identify their goals, unmet needs and resource requirements. Based on the assessment, the Care Coordinator assists the client and their care partners to formulate a plan to meet identified goals.

The Care Coordinator authorizes services and makes referrals/linkages to other professional and volunteer resources, to assess and support community-dwelling clients for as long as possible. They work with interprofessional teams to facilitate hospital discharge to return to the community.

Care Coordinators work in the community, hospital or long term care facilities. They are fiscally responsible for the care, services, and equipment they authorize within available Department of Seniors and Long Term Care policies and programs. In exceptional circumstances, Care Coordinators work with clients to articulate and advocate for alternative solutions to address unmet needs. They maintain ongoing communication with clients, family, caregivers, care providers and health care teams within the client's identified circle of care. The philosophy of the Care Coordinators is grounded in "Home First": maximizing available services and resources to support clients and families in the home/community. They are responsible for reassessments at routine intervals, and skilled care management.