The South East Local Health Integration Network (LHIN) is responsible for planning, managing and funding health care at the local level, as well as the delivery and coordination of home and community care. One of 14 LHINs established by the Government of Ontario, the South East LHIN is driven to design and deliver quality, patient-centred health care to achieve the vision of “Better System, Better Care” and meet the needs of residents who call this region home.
Committed to ensuring health care services maximize available resources, are aligned with regional and provincial priorities, and meet local needs and priorities, the LHIN continues to work with the Ministry of Health and Long-Term Care, in partnership with patients, families, health service providers and health care innovators to transform the health care system in Ontario – today and into the future.
The South East region extends from Brighton on the west, to Prescott and Cardinal on the east, north to Perth and Smith Falls, and back to Bancroft. The boundaries are for funding and planning purposes only. Residents of the South East LHIN can seek health care services wherever they prefer, inside or outside these boundaries.
Care Coordinators are responsible for patient assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all patient service programs (in-home and placement), including the provision of community resource information and referral. Care Coordinators are health system navigators who link patients with the right information and resources to help them achieve their short and long-term health care goals.
Health and Safety:
- Assesses referred patients for eligibility of services utilizing established criteria;
- Assists in identifying complex patients within the LHIN in accordance with the Health Link definition of complex
- Assists ineligible patients to access information/services appropriate to their needs and provides information on community resources and assistance to access the same where required;
- Acts as primary contact for patients, communicating with patients, caregivers, contracted service providers, primary care and Health Link partners regarding service plans;
- Collaborates with the patient, caregiver and/or family, and appropriate members of the patient’s health team related to service plan development , priority determination, authorization of services, development of mutual goals, and anticipated duration of service(s) outlined;
- Provides Care Coordination for identified Health Link patients and coordinates the primary Care Coordinator assignment with applicable Health Link partner
- Coordinates the delivery of quality, cost effective, equitable and timely services;
- Collaborates with service providers and other system partners;
- Fosters overall integration with primary care to develop strong working relationships centered on integrated patient care
- Maintains patient records which support ongoing assessment and monitoring, and meets the relevant discipline and standards, and documents both written and electronically, in accordance with the College and other standards to support the team;
- Effectively communicates with all appropriate members of the patient’s healthcare team via established communication channels including case conferences and home visits to optimize care planning and appropriate services;
- In collaboration with appropriate others, adjusts the service plan based on changes in the patient’s needs;
- Conducts home visits on a regular basis and as needed in accordance with patient needs and organizational policies;
- Counsels patients on placement process utilizing established criteria and guidelines for patients seeking placement, obtains consent, completes functional, psychosocial, medical and financial documentation;
- Advocates for the patient to facilitate positive patient outcomes;
- Determines the patient’s continuing eligibility for services and provides counseling and referral to other providers/agencies when service is decreased or discontinued, or when additional outside agency support is required;
- Conducts reassessments for patients awaiting placement;
- Discharges patient from service and redirects to/facilitates alternative resources, if applicable and assists with access such services, if needed by the patient;
- Promotes, educates and interprets the role and services of the South East LHIN to individuals, groups and community agencies, and health care partners;
- Participates in data collection activities as required;
- Assists with the orientation of new staff/students and carries out preceptor responsibilities as required;
- Maintains confidentiality and privacy by safeguarding patient information in accordance with legislation, professional college standards and South East LHIN policy;
- Initiates and maintains comprehensive service records for each patient;
- Identifies and participates in ongoing professional development and staff education;
- Performs other duties that may be assigned.
- Follows safe work procedures;
- Reports injuries and illnesses;
- Plans and carries out work both internally and externally in a safe manner;
- Abides by all legislative requirements, and related policies and procedures;
- Participates in related training and development, e.g. WHMIS;
- Maintains competency related to organization’s Emergency Response Plan, e.g. participates in planned tests. Reports unsafe or unhealthy working conditions;
- Is a ‘competent person’ as defined by the Occupational Health and Safety Act, and responsible for duties as outlined in the Occupational Health and Safety Act in section 28 (1) (2).
Minimum Qualifications & Position Requirements
- Holds current appropriate unrestricted registration as a member of one of the following: the College of Nurses of Ontario, the College of Audiologists and Speech Language Pathologists of Ontario, the College of Occupational Therapists of Ontario, the College of Physicians and Surgeons of Ontario, the College of Physiotherapists of Ontario, the College of Psychologists of Ontario or is a member holding a certificate of registration as a Social Worker with the College of Social Workers and Social Services Workers of Ontario;
- University degree in Nursing, Physiotherapy, Occupational Therapy, Speech Language Pathology, Social Work;
- Experience in community practice engaged in either case management or multi-disciplinary approach to patient care is preferred;
- Demonstrated computer literacy is required to facilitate the use of automated patient information systems;
- Vehicle and valid Ontario driver’s licence is required;
- Ability to communicate effectively both orally and in writing in English is required
- Ability to communicate effectively orally in French is considered as asset.
- New and existing employees must have the ability to access applicable health care partner information systems as a condition of employment.
- Committed to patient-focused care;
- Proven ability to manage time effectively, i.e. organize work, meet deadlines, set priorities, multi-task, and delegate effectively;
- Effective interpersonal and communication skills;
- Demonstrated leadership skills and proven ability to work effectively both as a member of a team and independently;
- Proven assessment, goal-setting, problem-solving, decision-making, and crisis management skills;
- Demonstrated commitment to maintaining cooperative and collaborative relationships with partners and colleagues;
- Willingness to be flexible and facilitate change;
- Proficient in working in a computerized environment.
The South East LHIN invites applications from all qualified individuals. We thank all applicants for their interest; however only those selected for an interview will be contacted. The South East LHIN provides support in its recruitment processes to applicants with disabilities, including accommodation that takes into account an applicant's accessibility needs. Candidates requiring accommodation during the recruitment process are asked to contact Human Resources. Accommodation will be provided in accordance with Ontario’s Human Rights Code and the Accessibility for Ontarians with Disabilities Act . The South East LHIN is an equal opportunity employer.