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Clinical Care Coordinator

Closing Date:
Open until position filled
Job Summary:

As a member of the Acute Home Care team, the Clinical Care Coordinator supports a population of patients with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) who are admitted to hospital or present in the Emergency Department.   These more complex, chronic patients are often discharged home with a limited level of support as they transition back to the community.   

The Clinical Care Coordinator will effectively engage and collaborate with hospital, primary and community care partners to:

  • Provide clinical assessment and intervention for COPD and CHF patients with moderate levels of care need to support earlier discharge from hospital
  • Provide care coordination for patients as they transition from hospital to home
  • Use best evidence available to support the patient towards increased self-management and maintenance at home to avoid future ER visits/hospitalizations (post-hospital home clinic for up to 60 days). 

Reporting to the Telehomecare and Acute Home Care Program Lead your responsibilities will include:

  • Complete intake assessment in the home and develop clinical care plan upon admission and project a discharge/transition plan
  • Progress the patient through the clinical care pathways in partnership with the Acute Home Care Team
  • Collaborate in creating the discharge/transition plan including progression to self-management
  • Take action regarding new referrals, identifying and connecting with patients and their circle of care (hospital, primary care, community) to develop and build relationships
  • Gather initial and ongoing information using standardized assessment tools to support the patient to be discharged home in a safe and timely manner
  • Make referrals to a wide variety of community supports and assist patients and their families through the process

Your qualifications and experience will include:

  • Registered Nurse in good standing with a regulatory body in Ontario
  • Minimum of five (5) years of relevant experience as a Registered Nurse (BScN or diploma) preferably with ICU, ED, Medicine, Respirology and/or Cardiology experience
  • Current clinical experience or clinical experience within the last three (3) to six (6) months
  • Completion of a COPD/CHF Educator Program
  • Clinical expertise in COPD/CHF care
  • Change Management and Planning and Evaluation skills
  • Working knowledge of community resources and roles of health care professional
  • Solid knowledge of health care related legislation and practices
  • Knowledge of direct care and care coordination models used in community health care organizations
  • Effective interpersonal and communication skills
  • Effective organizational and planning skills
  • Basic proficiency with computerized information systems
  • Able to communicate with patients', their families, and other relevant individuals in order to follow through with care plan directives
  • Demonstrated awareness of cultural diversity, as well as ability to behave discreetly and sensitively to confidential issues
  • Practical knowledge of relevant legislation (e.g., Long Term Care Act, privacy legislation, etc.)
  • Project Management Certification an asset
  • Must have a valid driver's license and access to a vehicle
  • French language is an asset

This is a Clinical Care Coordinator position for the South West CCAC with a home office in the London location.   Periodic travel throughout the South West region may be required.

To apply for this position, please visit Application deadline is July 15, 2015.

We thank all applicants who take the time to apply.  However, only those invited for an interview will be contacted.  We welcome applications from people of diverse backgrounds.

About the CCAC

Community Care Access Centres (CCACs) connect people across Ontario with quality in‐home and community‐based health care. CCACs provide information, access to qualified care providers and community‐based services to help people come home from hospital or live independently at home.