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Pinecrest-Queensway Community Health Centre

Pinecrest-Queensway Community Health Centre

Position:  Health Links Care Coordinator

Region:  Ottawa

Description:  

JOB #: 2018-0100

Job Summary
There are currently five Health Link networks in the Champlain region. Through partnerships with organizations such as community hospitals, addictions and mental health agencies, primary health care service providers, community support services and social service agencies, these Health Links work to improve health outcomes for people with complex health conditions. The Health Link networks are committed to increasing the level of, and access to, primary health services through an integrated team of health care professionals providing client-centered approach to care coordination resulting in improved management of chronic disease.

Role - The Care Coordinator will function as a member of the Western Health Link team with a prospect of evolving into a Health Links Coach. The Care Coordinator provides services to clients who include the individual, the family, and the community, with a strong emphasis on continuity of care, and seamless transition from all phases of the continuum of care for the identified population. In addition, care coordinator will support the development, implementation, monitoring and evaluation of programs and services of the Health Links with the Health Link Project Team and regional partners.

Job Specific Responsibilities

Direct Client Care and Support

  • The Care Coordinator focuses his/her attention of coordinating the transitions and participates in the development, implementation, monitoring and evaluation of programs and services of the Health Link client population, families and the community with the Health Link Implementation Manager and lead agency.
  • Organizes and supports training and coaching opportunities for providers in the partner agencies to build capacity within partner agencies for care co-ordination, as appropriate.
  • The care coordinator is expected to assist clients in identifying and establishing personal goals.
  • The Care coordinator is expected to develop a “Coordinated care plan” with the client that will outline and summarize clients care team and support network, current health conditions and outline range of client needs and personal goals, as well barriers to obtaining those goals.
  • With the client’s consent, include participating from members of the client’s network and organize a “care conference” in order to ensure effective communication between various service providers about what is important to client and who will be able to provide support around specific needs.
  • Supports the triage process for clients referred to the Health link in accordance with the appropriate protocols.
  • Receives and reviews hospital discharge/care coordination plans.
  • Liaises with client(s), caregivers, hospital core team and extended team, identified community resources and receiving providers to assist in developing client-driven coordinated care plans based on best practices.
  • Ensures that care plans are implemented in collaboration with client(s), the care team, and primary care providers in the circle of care. The care will be located both in the hospital and community sector including home visits.
  • Ensures client(s) actively participate in their own care planning and care by asking questions and reporting treatment or situations they don’t understand or feel comfortable with.
  • Provide support, encouragement, information and feedback to enable clients to realize their goals.
  • Ensures common understanding and participation by client and service providers towards the achievement of the care plan within defined timeframes and criteria.
  • Facilitates the implementation of the multi-disciplinary service plan to meet the client’s needs.
  • Collaborates and partners with the networks of providers to ensure successful implementation or modification of care plan.
  • Facilitates the client’s access to appropriate community or alternate resources.
  • Through regular support, based on assessment and reassessment and in collaboration with other partners, adjusts the care plan based on changes in the client’s needs and strengths.
  • Maintains open communication with service providers, conducts care conference and regular home visits to optimize care planning and appropriate services.
  • Keeps complete, accurate, legible and timely records of client’s visits, which will provide information to assist other practitioners in continuing the client’s care.
  • Provides regular reports to core team, primary care providers, service providers, clients, families and other authorized parties as required.
  • Works within the protocols established and approved by the Health Link protocols when required.
  • Provide services in the client’s environment of choice (home visits or other community locations, as appropriate), during regular and extended hours as required.
  • Provide services in a flexible manner.

Education, Advocacy and Community Relations
  • Provides training and coaching to other professionals in the partner agencies to enhance care coordination resources within Health Links.
  • Helps clients to identify and use health resources.
  • Involves clients in decisions about their own health.
  • Encourages clients to take action for their own health.
  • Develops learning resources for clients or uses existing ones (accurate).
  • Initiates and support health education activities.
  • Uses community assessment approach to identify community needs and resources and develops, implements and evaluates appropriate programming.
  • Represents the goals of the project to the community, including networks, meetings or presentations, as requested.
  • Participates in building creative supportive environments for providers and for clients.
  • Targets strategies to foster broader results within the family and looks at the determinants of health of this specific cohort.
  • Maintain relations with networks, related professional organizations and programs, as well as other related service providers.
  • Participates in community meetings as requi

Referrals/Collaboration
  • Collaborates with other health care providers.
  • Coordinates client care.

Organizational Role:
  • Supports the care coordination of approximately 36-50 clients through the year.
  • Provides cost effective, equitable, timely and non-judgmental support.
  • Is actively involved in the development of other professionals in the role of care coordinator through coaching and training.
  • Assists in the planning, implementation and evaluation of the project deliverables.
  • Ensures data has been collected and recorded as required for statistical/reporting purposes and participates in their analysis.
  • Provides timely and informative reports as directed and requested by the Implementation Manager, the lead agency (PQCHC) and Health Observes, collects and records client data in the EMR systems (CHC, FHT, Hospital and LHIN) as required.
  • When required, assists in the development and implementation of the clinical model and guidelines for collaborative care.
  • Identifies gaps and needed modifications in services.
  • Assists in the planning, implementation and evaluation of the Health Link.
  • Maintains current knowledge of Health Link mandate reads minutes of meetings and keeps up to date with Health Link happenings.
  • Contributes to the efficient functioning of Health Link and the attainment of goals.
  • Arranges priorities as necessary to perform tasks.
  • Familiarizes with established work and administrative procedures.

Team Development
  • Participates in team building activities/meetings of Health Links team and dispersed model of Health Links program development, and improvement activities.
  • Stays current and aware of opportunities to implement new, evidenced-based methods of client assessment, support, engagement and programming.
  • Participates in clinical projects/studies as required.

Professional Development
  • Maintains and develops professional competence through ongoing professional development. Fully participates in the Quality Assurance Program of the Care Coordinator respective professional college where applicable.
  • Prepares an annual learning plan that is in line with the health links work plan and individual needs of the employee to perform his/her role competently.
  • Participates in annual performance appraisal; discuss professional development and personal performance concerns.
  • Develops updates and maintains education resources.
  • Participates in continuing education activities to continually upgrade skills, abilities and knowledge to meet the demands of the position (attend relevant conferences, workshops and other in-service events as approved).

Related Duties
  • Models the values and philosophy of the Health Links.
  • Assists with planning and attends special events as required by Health Links.
  • Performs other related duties as assigned by the lead agency designate (Program Manager) or CEO.
  • Willingness and ability to travel within the sub-region with own transportation.

Qualifications

Education
  • Degree in related field: social work, counselling, physiotherapy, occupational therapy, recreational therapy, nursing (Master’s level preferred)
  • Current Registration with a professional regulatory body
  • Current Ontario Driver’s License
  • Valid basic CPR certification

Professional Experience
  • Demonstrated experience in Community and/or Primary Care Setting that includes client counselling, case management and discharge planning.
  • Experience working with, collaborating and linking with other community health and social service agencies.
  • Knowledge of community resources, and strong understanding of the health care environment in Champlain and in Ontario.
  • Knowledge of client-centered approach and strengths based philosophy, change management, basic principles and practices of community service delivery, and chronic disease management models.
  • Motivational Interviewing practice and skills. Experience working in the area of intensive case management with complex clients is an asset.
  • Mental Health First Aid education and experience is an asset.



Salary:  $32.798-$38.586 / hour

Terms of Employment:  Contract, December 15, 2018 – March 31, 2020

Deadline for Application:  Friday, November 23, 2018

How to Apply:  

Apply Online by Friday, November 23, 2018 at 4:00pm.

PQCHC is an equal opportunity employer and values diversity in its workforce.

If at any stage in the selection process you require an accommodation due to a disability, please let us know the nature of the required accommodation.




Location:  สล็อตออนไลน์Ottawa

Profession Type:  Case Management

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