CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker, dietitian, or speech-language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

As a Bilingual Hospital Care Coordinator , you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health‑care practitioners.

Whether you work in our office, in the community, or a health‑care facility, you will play a lead role in providing connected, accessible, patient‑centred care and will be supported by our team-oriented team that includes over 9,000 regulated health‑care and other professionals.

As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work‑life balance.

What will you do?

Under the general direction of the Manager, Patient Services and in accordance with the Ontario Health atHome Champlain standards, legislation, policies and guidelines, the Care Coordinator is responsible for client assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all client service programs (home care and placement), including the provision of community resource information and referral.

As a member of the Hospital Care Team, the Care Coordinator will work collaboratively with patients, families, caregivers, and hospital partners to develop a care plan to support a safe transfer from hospital to home for both complex and non‑complex patients. Care Coordinators must prioritize work based on the ever‑changing needs of patients and the hospital environment while meeting the Ontario Health atHome Champlain Guidelines of Care. The Care Coordinator will participate in various meetings to support care planning and communication with partners within the circle of care, including family meetings, care conferences, bullet rounds, and joint discharge rounds.

Primary Responsibilities





- Identification and Engagement – Assesses referred clients for admission and establishes a helping relationship with eligible clients and their families while honoring the client’s values and preferences.
- Assessment – Performs multidimensional assessment and identifies the need for crisis intervention and/or prevention strategies.
- Goal Setting and Service Planning – Establishes a care and service plan balancing client’s needs, choices and available resources. Develops a care plan in collaboration with the client, other health‑care professionals, care providers or family, stating priorities, services authorized, mutual goals and anticipated duration of service.
- Accessing Resources and Linking – Collaborates and partners with the networks of service providers.
- Service Implementation – Initiates and authorizes the implementation of the care plan.
- Accountability, Monitoring and Reassessment – Reviews and maintains the care plan in compliance with quality standards, outcome measures, quality indicators.
- Discharge Planning – Conducts discharges from the service process and/or redirects clients and families to alternative resources.

What must you have?

- Registered Nurse (BScN or diploma) and registered with the College of Nurses of Ontario; or
- Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
- Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
- Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers; or
- Degree in Speech Therapy and registered with the College of Audiologists and Speech‑Language Pathologists of Ontario; or
- Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
- All of the above require at least 2 years related professional experience.
- We have a mandatory COVID‑19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID‑19 vaccination status prior to start date.

Knowledge





- Knowledge of the health‑care delivery system and community resources within the Champlain region.
- Medical conditions and cognitive/psychiatric disorders.
- Client‑centred, multi‑disciplinary team approach to client care.
- Proficient in the use of computerized processes including the use of mobile (laptop) technology.

Skills and Abilities

- Demonstrates effective time management and organizational skills.
- Effective decision‑making and problem‑solving in crisis situations.
- Ability to negotiate and implement an effective goal‑oriented, client‑centred care plan.
- Team player with the ability to accept and adapt to change.
- Ability to maintain a positive attitude in stressful situations.
- Ability to organize daily workload in the presence of frequent interruptions.
- Fluency in English and French is required.
- Vulnerable Sector Check completed within the last six months.
- Valid N95 Mask Fit Test results or documentation of a medical exception within the past two years.

Hours of Work

A rotating shift schedule comprised of twelve‑hour shifts starting from 8 am and 8 pm, seven days a week for a total of 70 hours biweekly.

What do we offer?

- Attractive comprehensive compensation packages and advantages.
- Valuable development opportunities.
- Membership in a world‑class defined benefit pension plan.
- Salary Range: $44,480 - $47,517.

Who are we?

Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, hospitals, long‑term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient‑centred care.

Why join us?

If you’re interested in driving excellence in care and service delivery and seeking an unparalleled prospect 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 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. This job posting is for an existing vacancy.

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📌 Bilingual Care Coordinator, Regular Full-Time, Ottawa General Hospital
🏢 Ontario Health atHome
📍 Ottawa