Continuing Care Coordinator - Continuing Care

Nova Scotia Health Authority•Amherst, NY

About The Position

The Care Coordinator assesses clients referred to Continuing Care, develops care plans, authorizes services, and provides ongoing case management. The role helps individuals and families manage complicated acute or chronic health situations in the community by identifying goals, unmet needs, and resource requirements, then working with clients and care partners to plan for those needs. Care Coordinators authorize services and connect clients with professional and volunteer resources to support them in the community for as long as possible. They collaborate with interprofessional teams to facilitate hospital discharge back to the community and may work in community, hospital, or long-term care settings. Within applicable Department of Seniors and Long Term Care policies and programs, they are fiscally responsible for the care, services, and equipment they authorize. In exceptional circumstances, they help clients advocate for alternatives to address unmet needs. The role involves ongoing communication with clients, families, caregivers, care providers, and health care teams in the client's circle of care. Guided by a “Home First” philosophy, Care Coordinators maximize available services and resources to support clients and families at home or in the community. They also conduct routine reassessments and provide skilled care management.

Requirements

Bachelor’s degree in Nursing, Social Work, Occupational Therapy, Physiotherapy, or Nutritional Studies.
Current and ongoing registration, or eligibility for registration, with the applicable Nova Scotia professional regulatory body.
Minimum three years of related experience.
Knowledge and/or experience in a community or long-term care setting.
Knowledge and/or experience in dedicated case management or discharge planning.
Competence with computer use and keyboarding, including conducting assessments using a laptop.
Knowledge of community agencies and resources.
Excellent assessment, interviewing, and negotiation skills.
Excellent verbal and written communication skills.
Ability to work independently and cooperatively in a busy multidisciplinary situation.
Ability to multitask, prioritize workload, and manage time efficiently.
Valid driver's license and access to a reliable vehicle.

Nice To Haves

Competencies in other languages; French is an asset.

Responsibilities

Assess clients referred to Continuing Care.
Develop care plans based on clients’ goals, unmet needs, and resource requirements.
Authorize services and make referrals or connections to professional and volunteer resources.
Provide ongoing case management and routine reassessments.
Work with interprofessional teams to facilitate hospital discharge to the community.
Manage authorized care, services, and equipment within applicable policies and programs.
Help clients advocate for alternative solutions to unmet needs in exceptional circumstances.
Maintain communication with clients, families, caregivers, care providers, and health care teams.