Collaborative Care Coordinator

Competition #: 000738
The Position is: Full-Time
Hours of Work (shifts): Days



  • Healthcare Professional with demonstrated clinical assessment skills
  • Bachelor’s degree in a Health Discipline
  • Nursing, Respiratory Therapy, Occupational Therapy, or Physical Therapy preferred
  • Registration with appropriate regulatory college  (e.g. CNO, CRTO, COTO, CPO)
  • Member of relevant professional association/network preferred
  • Minimum of 4 years clinical experience caring for patients with COPD
  • Demonstrated clinical assessment skills including the ability to assess clients from pre-admission to post discharge
  • Knowledge of external agencies and resources
  • Demonstrated ability to partner and work effectively with all levels of staff, the interprofessional team, physicians, patients, families and external agencies
  • Demonstrated ability to deal with complex mental health and behavioral issues
  • Ability to maintain effectiveness in varying environments and with different tasks, responsibilities and people
  • Demonstrated knowledge of and ability to provide patient centred care. Demonstrated organizational, problem solving, interpersonal, coaching, negotiation and facilitation skills
  • Strong organizational skills to work independently in an unstructured, demanding environment
  • Demonstrated reliable work habits
  • Ability to work a flexible schedule
  • Strong Windows based computer skills e.g. Microsoft Office Suite
  • Fluency in a language other than English an asset
  • Experience in the clinical setting for which the individual has been hired preferred
  • Evidence of satisfactory attendance record
  • An employee’s disciplinary record will be reviewed as part of the assessment of qualifications
  • Ability to work in a manner that exemplifies the centre’s core values and helps patients get their life back
  • Should be aware of conditions and measures that may affect the safety of patients, residents, students, employees, volunteers, physicians and visitors



  • Assess patients referred from acute care and/or the community for appropriate admission to West Park  and/or link with appropriate services in the community as part of the COPD Pathway
  • Facilitate rapid access to services, pulling patients from acute care via early assessment and adherence to evidence-based criteria
  • Work closely with the patient (and family) on goal-setting
  • Provide intensive case management for a caseload of up to 40 patients for a defined period (approximately 6 months)
  • Act as the point of contact/liaison between members of the collaborative care team
  • Coordinate, monitor, and facilitate patient’s plan of care; emphasizing early engagement of primary care and  involving community partners, as appropriate
  • Organize systematic case reviews with the collaborative care team
  • Provide education to patient/family; coordinate development of self-management plan
  • Assist patients in navigating the healthcare system
  • Ensure delivery of evidence-based (best practice) patient management
  • Ensure baseline and follow-up outcomes are conducted; outcomes are based on evidence, and are team-based
  • Ensure collection of system-based metrics (i.e. volumes, wait time, health care utilization)
  • Perform other duties as assigned.


At West Park Healthcare Centre, we are committed to fostering an inclusive and accessible environment, an important part of living our brand. We are dedicated to building a workforce that reflects the diversity of the community. Our accessible employment practices are in compliance with the Accessibility for Ontarians with Disabilities Act, and the Ontario Human Rights Code. Should you require accommodation during any phase of the recruitment process, please indicate this in your cover letter. For further assistance please contact the Human Resources Department at (416) 243-3600 extension 4633.

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