Halton Healthcare Services Looking for Care Coordinator-PPT-Transitions and Integrated Care at [...]
: Job Details :

Ref #:916227Specific Department and Program:Transitions and Integrated CareLocation:Multi SitePosted Date:Mar 21, 2023Posting #: 2023- 916227Non UnionPosition: Remote Care Management Clinical CoordinatorDepartment: Connected Care Halton Ontario Health TeamStatus: Permanent Part-time (must provide availability of up to 0.5 FTE)Hours: Day time hours Monday- Friday (Hours are subject to change based on operational needs)Site: Oakville, Milton and Halton HillsHalton Healthcare's vision of Exemplary patient experiences, always, goes beyond just the patient experience; it has shaped our entire culture and remains at the core of every interaction in our organization, from our patients & families to our staff, physicians and volunteers. We believe in exemplary PEOPLE experiences always!At Halton Healthcare you will thrive in a healthcare culture and environment that embraces inclusion, diversity and belonging with Ë exemplary patient care, always' at the heart of everything we do.We empower our people to be the very best they can be so they can make a difference for our patients and the communities we serve.Halton Healthcare takes great pride in providing quality, compassionate healthcare services to our rapidly growing communities. As a progressive and vibrant healthcare organization, we are committed to being an innovative center of excellence in community hospital care.Overview:The program is a partnership between Halton Healthcare, Connected Care Halton Ontario Health Team, Home and Community Care Support Services and Halton Community Paramedicine. Aetonix provides the remote care management technology: . Patients on this program have their vital signs reviewed by a nurse remotely. Patients can connect easily with a member of the management team if they have questions and there is a thoughtful escalation process in place should concerns arise both during and after regular program hours. This service is intended to help support self-management in the home, promote a shorter hospital length of stay and ideally reduce emergency room visits and/or readmissions.The Remote Care Management Clinical Coordinator (RCMCC) will provide patient-centered system navigation, supporting the identification and on-boarding of patients eligible for the program within the Oakville, Milton and Halton Hills. Working collaboratively with an inter-professional team (including physicians), both internal and external to Halton Healthcare, including H&CCSS, Family Health Teams, Community Physicians, Halton Paramedicine, and specialty clinics to ensure patients are provided access to the support and benefits of Remote Care Management. Currently patients with COVID-19, COPD, CHF, Pneumonia and ILD are supported with a future expansion to Mental Health and Addictions and Palliative Care.This is what you'll be doing:Case Finding at Halton Healthcare hospital sites (25%)Attending hospital roundsCommunication of the benefits of the RCM program to physicians, care-coordinators, discharge planners, etc.Meet with care team to discuss LOS and barriers to discharge for eligible patientsAssist in the completion of RCM referral forms and ensure all paperwork is faxed to H&CCSS to initiate servicesCase finding and expansion of program to the community (40%)Teaching, promoting and sharing of RCM information to Family Health Teams and Community PhysiciansCommunication of the benefits of the RCM program to physicians, care-coordinators, Family Health Teams and outpatient clinics.Support the coordination of care and development for individualized care plans for patients with linkages across hospital, community and primary careSupport Oakville Cardiology Clinic to on-board eligible patientsSupport Halton Paramedicine to identify eligible patients and liaise with their primary care physician to arrange referrals for the RCM programProgram Coordination (25%)Track and document referrals from care providers (hospital and community) for the RCM program.Enter data related to patients on-boarded on the RCM program and those patients who have declined, etc.Work closely with the SCOPE/RCM navigator to scale and spread the RCM programReport to the weekly RCM partner huddles any challenges, barriers, successesSupport for Seamless Care Optimizing the Patient Experience (SCOPE) (10%)Provide Backup for the SCOPE Nurse NavigatorServe as a point of access to connect family physicians to appropriate community, clinical and specialized supports to address patient health concernsRespond to all calls and emails made to SCOPE Navigation Hub by the PCPs and their administrative assistantsTriage and forward referrals to appropriate SCOPE contact (i.e. Internist, Home and Community Care Coordinator, Imaging, Outpatient Clinics)Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)Understand and clarify PCP primary concerns and request for supportCollaborate with the health care team to improve patient care as they transition through the health care systemEnter data related to patients on-boarded on the RCM program and those patients who have declined, etc.This is what you'll need to do it:Master of Nursing or Related Discipline PreferredCurrent registration and membership in good standing with the College of Nurses of OntarioAt least 5 years' direct nursing experience within acute care requiredAt least 5 years' experience in primary / community care2-5 years' experience working within an inter-professional team environment, as well as independently and autonomously2-5 years' experience working with older patients with complex needsExperience in performing case management functions is requiredExcellent interpersonal, communication, organizational and decision making skills requiredConsistently demonstrated strong leadership skills, including problem solving, critical thinking, conflict resolution and negotiation skillsDemonstrated ability to work independently and collaboratively with an interdisciplinary team, family members, support networks, and a variety of formal and informal service providersExcellent time management and stress management skills requiredExperience with the MS suite of systemsMeditech experience preferredValid driver's licenseDate Posted: March 21, 2023Internal Applications Due by: March 28, 2023Please apply if you are passionate about what you do, motivated by a job well done, and as committed to excellence, quality and patient satisfaction as we are. Please submit your application via our website at directly to this posting and include a current copy of your resume.We thank all those who apply but only those individuals selected for further consideration will be contacted.In accordance with Directive #6, Halton Healthcare has implemented a COVID-19 Vaccination and Management Policy. All new hires must be fully compliant with our Policy as a condition of employment with Halton Healthcare. Successful applicants will be required to provide proof of vaccination or proof of a documented medical exemption as part of the hiring process.In accordance with the Accessibility for Ontarians with Disabilities Act and the Ontario Human Rights Code, Halton Healthcare will provide accommodations throughout the recruitment and selection process. If you require an accommodation, we will work with you to meet your accommodation needs to ensure your equal participation.All personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act.Halton Healthcare is a smoke free facility in and around all three sites. Smoking is not permitted on hospital properties. We thank everyone who works at or visits our hospitals for respecting this healthy initiative. We are also a scent-free environment for all employees and visitors to accommodate individuals' health concerns arising from exposure to scented products. We ask for everyone's cooperation in our efforts to accommodate health concerns.All Halton Healthcare staff, professional staff and volunteers are encouraged to be vigilant about identifying and reporting safety incidents in their everyday practice. They also have a role in analysis, recommendations and follow through to implementation.#J-18808-Ljbffr