Full-Time Unionized Position – ONA

Sarnia Site – Grand Bend Area Community Health Centre


Health Links is a philosophy of care. The Health Links approach to care facilitates a collaborative environment that assists the interdisciplinary health care team to develop new innovative ways to care for patients with complex chronic issues.

Reporting to the Patient Services Manager, the Clinical Care Coordinator’s responsible for providing a “hands-on” and an “in-home” support approach for patients. The Clinical Care Coordinator will provide patients with timely communication and linkage to primary care in order that these patients are able to live well with their chronic disease

 As an integral part of an interdisciplinary team, the Clinical Care Coordinator develops coordinated care plans to assist patients to live well with chronic disease. The expected outcome is reduced Emergency and hospital admissions and smooth transitions back to the patient’s home. The Clinical Care Coordinator provides an in-home nursing visit within 24 – 72 hours from hospital discharge for identified clientele. The Clinical Care Coordinator conducts a comprehensive nursing assessment, using a patient and family centered approach and works with the patient and their supports to develop a coordinated service plan including medication reconciliation.

Additionally, this position is responsible for developing quality, timely and cost effective individual service plans for service provision utilizing a multi-disciplinary approach to achieve optimal health outcomes. The purpose of this position is to provide clinical care as well as care coordination to meet the needs of their identified caseload.


  • Facilitates the development of Coordinated Care Plans (CCPs) for all identified Health Link patients
  • Conducts clinical nursing assessments and based on patients’ level of need and discharge destination provides assessment, advice and recommendations to the appropriate receiving agency in order to assist patients
  • Provides in home nursing care as required (teaching, assessment, monitoring) transitions to service provider
  • Conducts a comprehensive medication reconciliation
  • Develops collaborative working relationships with community partners and enhances existing work relationships with a broad range of community agencies, to ensure that caregivers are linked seamlessly to community agencies that can support the patient who will transition from various acute and sub-acute environments to home care
  • Collaborates with the patient/caregiver and care team, including primary care, contracted service providers and community support agencies, to develop and delivery care plans that are patient centered, meeting the patient’s identified needs and goals, so that the patient’s need to access the emergency room and hospital is reduced
  • Authorizes all services, medical supplies and equipment necessary to achieve the established program goal; obtains special authorization as required
  • Provides for IHH (Intensive Hospital to Home) service planning as appropriate
  • Ensures the fiscally responsible use of appropriate resources to achieve the desired outcomes by mobilizing and integrating formal and informal patient support networks
  • Collaborates with the management team as needed to collect data and reports as required
  • Assesses and promotes a safe environment for patients, caregivers, family members, and staff.
  • Adheres to policies and practices developed and implemented by the LHIN.
  • Shares information according to privacy guidelines
  • Participates in establishing, maintaining, and monitoring standards for case This includes committee work and active participation and contribution to quality and educational initiatives.

Community Engagement

  • Acts as a spokesperson as required, and interprets the role of the LHIN to patients, health care professionals and to the
  • Demonstrates behaviours, actions and attitudes that are professional and consistent with the Erie St. Clair LHIN’s vision, mission and values
  • Demonstrates political sensitivity in all interactions
  • Promote and include Indigenous cultural models of care and community centered care approach

Team Building

  • Develops professional working relationships with team members
  • Works respectfully, positively and collaboratively within a team environment, sharing experiences and lessons learned
  • Supports the team and work with team members to ensure departmental needs are met

Other Related Activities

  • Strives to achieve continuous quality improvement and excellence in all activities and outcomes
  • Implements new procedures and controls deemed necessary by management
  • Assists in the training and orientation of peers
  • Travels throughout the Erie St. Clair as required
  • Other duties as assigned


  • A Baccalaureate degree from a recognized university in the field of Nursing (and/or a combination of nursing education, training and experience) holding current registration with a regulated college in Ontario
  • Minimum 2 years of relevant experience in a clinical setting as a Registered Nurse working in the acute care setting
  • Registered Nurse working in a clinical setting such as hospital, physician office setting. Sound knowledge of the Ontario health care system and working knowledge of community resources and roles of health care professionals
  • Preference will be given to an individual who is strongly affiliated with Indigenous culture and traditions and has worked in a First Nations community
  • Working knowledge of the nursing process, the consultation process, program planning and crisis management
  • Emergency/critical care and community nursing experience
  • Canadian Nurses Association (CNA) certification in an area of specialty: Certificate in Geriatric Nursing (GNC) or Certified Nurse in Critical Care Pediatrics (CNCCP) an asset
  • Superior clinical assessment skills
  • Solid knowledge of health care related legislation and practices
  • Knowledge of direct care/case management models used in community health care Organizations to support system navigation and hospital avoidance
  • Must have a valid Driver’s License and access to a reliable motor vehicle with appropriate business class liability insurance
  • Geriatric experience is an asset
  • French Language is an asset


The 14 Local Health Integration Networks (LHINs) are organizations that plan, coordinate, integrate, and fund health care services. In addition, as outlined in the Patient’s First Act, the LHINS are also responsible for overseeing the delivery of home care services in the region. LHINs are a critical part of the evolution of health care in Ontario. They continue to work to create a patient-centered, results-driven, integrated, and sustainable health system.

 The Erie St. Clair LHIN services the regions of Chatham-Kent, Sarnia/Lambton, and Windsor/Essex which includes approximately 650,000 people, and supports an annual budget of over $1.2 billion dollars for our local health care services.

The Erie St. Clair LHIN has a need for a Clinical Care Coordinator as described below. The Erie St. Clair LHIN is committed to supporting healthcare in a manner that is consistent with patient and family centered care.  Applicants are required to have a demonstrated understanding and commitment to this care philosophy. This position understands expectations around the quality and safety framework and participates in safety and quality initiatives, gathering and analyzing information as required. This position also requires a high degree of attention to detail and excellent time management skills. Preference will be given to candidates who are proficient in both official languages. The position is located at the Grand Bend and Area Community Health Centre and will be supporting home and community care deliverables.

Travel is required within Lambton County of the ESC LHIN.

LHIN 047/19 Clinical Care Coordinator

STARTING DATE: As soon as possible
HOURS OF WORK: 37.5 hours per week
SALARY RANGE: In accordance with the Collective Agreement

To Apply…

Please submit your cover letter and resume no later than 4:30PM, November 15, 2019 to Resume@lhins.on.ca

Please include the reference “LHIN 047/19 Clinical Care Coordinator” in your e-mail subject line.

By submitting an application, applicants are consenting to the sharing of their personal information with individuals from the ESC LHIN who are participating in the selection process.

The Erie St. Clair LHIN is an equal opportunity employer. Individuals with a disability requiring accommodation during the application and/or the interview process should advise the recruitment contact so arrangements can be made.

*We thank all applicants for their interest, but advise that only those selected for an interview will be contacted.