Care Coordinator (Durham OHT LP)

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 are to: 

1. 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.
2. 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.
3. 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.
4. 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.
5. Expand understanding of home care delivery by OHT partners, including care coordination roles and responsibilities.
6. 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. 

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. In supporting the development of a robust coordinated care plan, the Care Coordinator (CC) may connect the patients to additional resources and supports in the broader system.    

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 preference of care. CCs 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 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 being met to achieve their goals of care. CCs will also carry out their duties in accordance with OH atHome policies and the 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.  

CCs report to an OH atHome Patient Services Manager for employment-related matters and are accountable to the LP OHT for advancing integrated, team-based care. 

With shared accountability between OH atHome and the OHT, with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, CCs connected with an OHT LP 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 CC 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. 

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 per MOH and OH direction. OH atHome CCs will ensure comprehensive system navigation, and work alongside the One Care Team to ensure patient risks are identified and patient’s care needs and goals are maintained.   

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 and other interRAI assessments;
• Making determinations of eligibility;
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change; and
• Terminating the provision of a service.

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

• Revising care plans (i.e. – number of visits, types of services) based on clinical expertise, within the context of the approved model of care, and in accordance with written arrangements between the LP HSP and the HSP or SPO performing these care coordination functions;
• 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 the LP HSP, such as mental health and addictions, housing, community supports, etc.;
• Providing information about - and referrals to - providers of other health and social services.

What must you have?

• Regulated health care professional (RHP) holding current registration in good standing with a regulated college in Ontario in one of the following health disciplines: nursing (RN), physiotherapy, occupational therapy, medical social work, dietetics, or speech-language pathology; 
• Appropriate university degree or a suitable combination of education and direct experience;
• Field of registration must allow applicant to determine patient capacity in accordance with the Health Care Consent Act (1996); 
• 1-3 years of experience in community health or a related field;
• Minimum 2-3 years of relevant recent experience as a Regulated Health Professional working in a clinical setting such as hospital, physician office setting;
• Sound knowledge of the Ontario healthcare system, the role of CC as assessor and health planner, all relevant legislation and available local community resources;
• Basic knowledge of and adherence to relevant legislation and regulations, including the Home and Community Care Services Regulation of the Connecting Care Act, 2019 and Personal Health Information Protection Act (PHIPA);
• Basic understanding of issues and priorities within the healthcare sector;
• Good knowledge of home care patient services strategies, objective, priorities;
• Knowledge of direct care/case management models used in community health care organizations to support system navigation and hospital avoidance;
• Working knowledge of the nursing, process, the consultation process, program planning and crisis management; 
• Superior clinical assessment skills;
• Knowledge of and adherence to identified OH atHome and LP OHT policies, procedures and related practices; 
• Solid ability to use MS Office applications (e.g. Word, Excel, Outlook, PowerPoint, etc.) and internet research skills and computer navigation is required;
• Strong understanding and commitment to quality service and best practice;
• Ability to analyze information, problem-solve and make good decisions;
• Accountable for own actions and decisions, making decisions within the scope of the position and referring issues/problems/events to the Patient Services Manager for employment related matters and referring issues related to the integrated care model to the OHT lead as required;   
• Solid documentation skills (clear, thorough, accurate and timely);
• Self-directed with the ability to organize, prioritize and multi-task;
• Flexible, adaptable and responsive to change; 
• Detail-oriented;
• Strong written and verbal communication skills; 
• Courteous and respectful in all interactions; 
• Understanding of and ability to practice culturally safe and trauma-informed care, particularly when serving Indigenous clients and families;
• Ability to establish and maintain a wide range of contacts with professionals and organizations within the community;
• Solid effective listening and facilitation skills;
• Ability to maintain confidential information;
• Empathy to sensitive issues.

What would give you the edge?

• Community nursing experience is an asset;
• Ability to communicate in French or another language an asset.

Hours of work:

All hours of operation (Initially Monday-Friday 0830-1630; 70 hours per bi-weekly pay period) subject to change as per the Collective Agreement.

Position location and travel:

Hybrid work model, subject to change. 

Regular travel within the geographical region of Ontario Health atHome Central East 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 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​
• Salary: $41.92-$51.91/hour 

Who we are

We are Ontario Health atHome, ready to serve every person in Ontario. Ontario Health atHome 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.

Date Posted: February 12, 2025

Closing Date: February 19, 2025

Job Type: Full-time

Start Date: March 3, 2025

Program: All Patient Services Programs

Branch: Whitby

Group: ONA