Job Description

Are you an experienced registered nurse 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 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-centered care – and be supported by our collaborative team that includes over 8,000 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-The Care Coordinator, Palliative Care is responsible for, or supports other Care Coordinators in managing, a caseload of palliative patients who are at different stages of illness trajectories and may require a palliative approach to care. The Care Coordinator, through home visits and/or phone conversations, measures the patient’s and caregiver’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s and caregiver’s wishes and preferences. He/she assists the patient and caregiver in navigating the health care system and also determines eligibility and refers to other community resources and programs, such as Hospice care and the Regional Palliative Consultation Team.

Primary Responsibilities:

• Completes comprehensive patient assessments using a validated palliative assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
• Assesses patient’s Palliative Performance Scale and eligibility for palliative and other services
• Assesses eligibility for hospice care and admission to palliative care units
• Develops an individualized care and service plan reflective of the patient’s identified priorities and desired outcomes; identifies strategies and resources to be used in attaining clinical outcomes
• Discusses plans for end-of-life care, goals of care and preferred place of death
• Coordinates and facilitates referrals and transfers to hospice and palliative care units
• Assists patients and caregivers in finding in-home palliative medical follow up and coverage
• Initiates and authorizes the implementation of the care plan through contracted providers, supplies and equipment necessary to achieve the care goals
• Maintains open communication with service providers, conducts case conferences and regular home visits to optimize care planning and appropriate services
• Partners with the Ontario Health atHome/Ottawa Hospital Medical Assistance in Dying (MAiD) Care Coordinator for those clients wanting and requiring assistance with MAiD.

Team/Department: Palliative

Hours of work: Monday to Friday – 8:30am to 4:30pm (35hrs/week)

FTE: 1.0

Length of Temporary Assignment: May 29, 2026

Starting Salary: $44.480 to $47.517

Affiliation: OPSEU

Office Location: Winchester

Reporting to: Manager, Patient Services

What must you have?

• Registered Nurse (BScN or diploma) with a current Certificate of Registration from the College of Nurses of Ontario
• Related professional nursing experience which is normally attained over a period of two years
• Palliative care experience that includes advance care planning, goals of care and end of life care planning
• Professional experience in health care should include linkage with other community health agencies, needs assessment, care coordination and/or discharge planning
• Canadian Nurses Association Certification in Hospice Palliative Care is an asset
• LEAP training is an asset
• Experience providing MAiD expertise are assets

What would give you the edge?

Knowledge:

• Knowledge of medical diagnoses and prognoses, symptom management, end-of-life care and cognitive/psychiatric disorders
• Knowledge of Champlain region Hospice and palliative care organizations and partners
• Knowledge of Hospice palliative care philosophy and approach
• Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Excel, Power Point, etc.)

Skills and Abilities:

• Effective planning, organizing, and evaluation skills to manage multiple patients, provide information reports, and take corrective action as required
• Ability to accurately complete required documentation, reports, forms, and recommendations
• Verbal and written communication skills to establish and maintain a wide range of partners (doctors, nurses, social workers, etc.) within the healthcare and Hospice community
• Ability to manages difficult conversations /situations such as advance care planning, goals of care, end-of-life and hospice care, and medical assistance in dying, in a healthy and effective manner
• Fluency in English and French is an asset.
• Vulnerable Sector Check completed within the last six months

Hours of Work

Monday to Friday – 8:30am to 4:30pm (35hrs/week)

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer: ​

• Attractive comprehensive compensation packages and benefits​
• Valuable development opportunities​
• Membership in a world class defined benefit pension plan​

Who are we?

We are 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-centered care.

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity 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 are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

All applications will be reviewed; however, only those selected for an interview will be contacted. Ontario Health atHome Champlain welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in any aspects of the selection process.

Ontario Health atHome has implemented a mandatory vaccination policy across the province that requires all staff to be fully vaccinated against COVID-19. Applicants being considered for employment will be required to provide proof of vaccination documentation confidentially to Human Resources upon hire. Any medical or human rights exemption requests will be reviewed and validated prior to an offer of employment.