Integrated Care Coordinator

Integrated Care Coordinator (ICC), as a member of the Integrated Comprehensive Care and Bundled Funding Program will provide patient centered system navigation, intensive case management and coordination of services to a selected group of clients as they access care within Hamilton Health Sciences and with partner organizations. The ICC will identify and facilitate access to the right services from the right provider at the right time based on assessed needs by working collaboratively with an inter-professional team, family members, support network, and a variety of informal and formal service providers. The ICC coordinator acts as a key resource to ICC Home Care staff and hospital staff regarding the ICC program and patients.

The ICC will coordinate seamless care transitions and will be responsible for exchanging knowledge related to respective health conditions and the continuum of services and resources to enhance client self-management and quality of care. The ICC will follow patients through the various care settings to ensure continuity of care. The ICC will also act as a liaison between Clients and providers of other Community Support Services. ICC program leverages cutting edge technology to support patient care and seamless transitions from hospital to community and ongoing community management.

The ICC will be responsible for ensuring cost effective client care by utilizing resources efficiently and collecting necessary data on client care to support the evaluation of outcomes of integrated care delivery.
1. Undergraduate Degree in Regulated Health Professional.
2. 3 to 5 years demonstrated expertise in chronic disease management, mental health and addictions, complex and dysfunctional family systems, older adults who are frail and/or palliative, medication and symptom management for Heart Failure and COPD.
3. Able to exchange knowledge related to specific health conditions and the continuum of services across sectors, and resources to enhance patient self-management and quality of care.
4. High degree of autonomy and independent decision-making on a daily basis related to work with clients, HHS and Home Care staff, Specialty Physicians, Primary Care Physicians and staff at other Hamilton and HNHB LHIN hospitals and community service agencies.
5. Prioritization of work based on client needs and program goals and development.
6. Excellent communication and leadership skills such as; problem solving, critical thinking, negotiating and conflict resolution.
7. Responsible for establishing and maintaining relationships with other health care professionals in designated specialty functions to ensure quality of care.
8. Excellent interpersonal, communication, organizational and decision making skills required.