As a member of the Clinical Resource Program, the Hospital 2 Home Coordinator will work with interdisciplinary hospital teams, primary care, specialists and community service providers to assist Hospital 2 Home patients to reach optimal function and health in an appropriate environment that will support their needs. Hospital 2 Home Coordinators will incorporate the best available evidence into practice. In addition, the Hospital 2 Home Coordinator will actively participate in professional development opportunities, professional practice and program committees, and initiatives that support patient care, clinical practice, education and research as approved by the Hamilton Health Sciences’ management team. The Hospital 2 Home Coordinator will be responsible for ensuring cost effective patient care by utilizing resources efficiently and collecting necessary data on client care to support the evaluation of outcomes of integrated care delivery.
Undergraduate Degree as a Regulated Health Professional is required. Master's Degree preferred.
Recent 3 to 5 years of demonstrated experience working with patients admitted to acute care with exacerbations of
chronic conditions such as Diabetes, Hypertension, COPD and Heart Failure.
Recent 3 to 5 years of demonstrated experience working with patients in the community/in patient’s home setting.
Recent 3 to 5 years of demonstrated expertise and competence in symptom management for common chronic
conditions such as Diabetes, Hypertension, COPD and Heart Failure.
Recent 3 to 5 years of demonstrated expertise and competence in assessment of health literacy and development of
interventions to assist patients who are not health literate.
Recent 3 to 5 years of demonstrated expertise and competence in assessment of determinants of health and
development of interventions to assist patients impacted by determinants of health.
Recent 3 to 5 years demonstrated expertise and competence in assisting patients and families to manage multi-morbidity
utilizing a chronic disease management framework and best practice guidelines.
Recent 3 to 5 years demonstrated expertise and competence working with patients diagnosed with dementia, mental
health conditions and addictions.
Recent demonstrated expertise utilizing and interpreting objective screening tools to assess cognition, depression, delirium and frailty.
Demonstrated expertise utilizing Health Quality Ontario's Coordinated Care Planning Tool.
Recent 3 to 5 years demonstrated expertise and competence working with seniors who are frail and/or palliative and their families.
Recent 3 to 5 years demonstrated comprehensive knowledge of community resources and health care delivery
systems in acute, primary care and community settings.
Demonstrated ability to respond to patients and situations with flexibility and adaptability required.
Demonstrated expertise and competence in case management.
Excellent interpersonal, communication, organizational and decision-making skills required.
Demonstrated leadership skills, including problem solving, critical thinking, conflict resolution and negotiation required.
Demonstrated ability to work independently and collaboratively with an interdisciplinary team, patients, families,
primary care, community services required.
Demonstrated expertise in quality improvement and change management methodology required.
Excellent time management and stress management skills required.
