Home Care Case Coordinator

QUALIFICATIONS
* Baccalaureate Degree in Nursing Required
* Eligible for active practicing nursing licensure with applicable regulatory body in the province of Manitoba
* Current Basic Cardiac Life Support (BCLS) Training as delineated in Prairie Mountain Health Policy PPG-00002 CPR Training
* 2 years of directly related community experience
* Experience working with elderly, young disabled, and palliative care clients
* Other combinations of nursing education and experience may be considered.
* Province of Manitoba Class 5 Drivers License, or equivalent from province of residence, and access to a personal vehicle to provide service within Prairie Mountain Health
* Proficiency with Microsoft programs (Outlook, Word, Excel, Access and PowerPoint), as well as Internet applications and other Information Technology
* Demonstrated organizational skills and ability to work independently
* Demonstrated problem solving and decision making skills
* Demonstrated flexibility to facilitate changes in techniques and procedures in a changing environment
* Demonstrated knowledge and competence of skills and concepts related to the position
* Demonstrated communication skills
* Ability to respect and promote confidentiality
* Ability to perform the duties of the position on a regular basis
* Ability to respect and promote a culturally diverse population
* Ability to work effectively and maintain positive working relationships with co-workers, clients and within interdisciplinary team

POSITION SUMMARY:

Reporting to the Home Care Manager, the Case Coordinator will operate with a high degree of independence as a member of the multidisciplinary team. The incumbent is responsible for providing a collaborative, client-driven process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human service needs through the effective and efficient use of resources within Home Care, Prairie Mountain Health and the community.

Incumbents will exercise professional judgment in the completion of their duties and action to be taken on unusual day to day matters. The position functions in a manner that is consistent with the mission, vision and values; and the policies of Prairie Mountain Health.

RESPONSIBILITIES:

Intake and Assessment

1. Receives and reviews referral information, prioritizes and determines eligibility for Home Care services or re-directs the referral appropriately
2. Conducts a comprehensive in-home client assessment of client/family determine eligibility and care needs related to Home Care and/or Personal Care Home admission or alternative.
3. Admits eligible cases to Home Care or re-directs appropriately.
4. Completes a home safety risk assessment to ensure a safe work environment.
5. Works collaboratively with client/family to provide holistic client centered care. This includes timely and effective communication with other Health Care Professionals during the provision of client care and at care transitions.
   
   Care Planning & Case Coordination
   In consultation and collaboration with client/family and interdisciplinary team:
6. Analyses data received from in-home assessment, identifies and prioritizes needs and strengths.
7. Plans and implements client centered goals, client care plans, and recommendations through clinical analysis of assessment findings appropriate for goal-oriented care.
8. Participates in the discharge planning process.
9. Refers or facilitates referrals to other professionals or agencies, as required.
10. Plans and organizes own work schedule.
11. Manages caseload demands effectively.
12. Carries out activities necessary to meet Program guidelines.
13. Completes long term care applications for submission to Panel Chair.

Monitoring and Evaluation

1. Manages client caseload including monitoring, evaluation, reassessment, and adjustment of the plan of care.
2. Participates in case reviews/conferences as assigned.
3. Submits regular reports as required and notifies manager of any critical situations that may impact the health/safety of assigned clients.
4. Communicates pertinent client information and needs or other relevant issues to Manager in a timely manner.
5. Gathers data concerning community resources and identified gaps in resources and reports same to Manager.
   
   Program Planning and Administration
6. Participates in interpreting the services and resources provided by Home Care to the public and/or other agencies.
7. Takes initiative to establish connections and maintains relationships with local health care services and the informal community resource network.
8. Self-directs and initiates appropriate decision making.
9. Participates in ongoing quality management through the development, implementation, and evaluation of services.
10. Participates in the development of program policies, guidelines and resources through review and revision as deemed necessary.
11. Provides ongoing evaluation of services and implementation of changes to facilitate best practice and delivery of services.
12. Establishes priorities and organizes daily schedule for designated caseload.
13. Completes required statistical reporting.
14. Attends staff meetings.
15. Submits requests for allocation and reconciliation of client related equipment and/or supplies.
16. Adheres to all Home Care Program policies and implements Policies and Procedures ensuring that program goals and care standards are met.

Team Collaboration

1. Provides ongoing information and guidance to other involved professionals and caregivers within the team to promote and increase awareness.
2. Provides consultation and information to family or other client care providers who will be administering and monitoring the client’s care plan.
3. Provides client teaching and recommendations to enhance client independence.
4. Shares client care plans and pertinent information with appropriate stakeholders to support a collaborative approach to client care.
5. Attends client care planning and program planning meetings as required.
6. Participates in the orientation and mentorship of new staff.
7. Provides coverage for other caseloads as necessary.
8. Participates in teaching and delegation of client-specific training to all team members.
   
   Professional Development
9. Identifies own educational needs and, in conjunction with the Home Care Manager, develops an educational pathway to meet those needs.
10. Participates in regular performance evaluations based on this position description.
11. Participates in Continuing Competency program as per their respective professional licensing body college.
12. Participates in activities of the professional associations and special interest groups.
13. Completes required regional and program education per PMH policy.
14. Participates and contributes to shared learning with home care staff and other health care providers.
15. Contributes to making the organization safe for patients, residents, clients and staff by recognizing the importance of reporting unsafe situations and participation in follow up reviews as a learning opportunity.
16. Pursuant to the Regional Health Authority Act, all employees accept responsibility to support clients in their official language of choice.
17. Other duties as assigned.