Salary Grade: 4
Job Summary
The Bundled Care Coordinator facilitates seamless care transitions across the care continuum for patients undergoing primary unilateral hip/knee total joint replacement. The Bundled Care Coordinator will act as the primary contact and resource for patients undergoing total joint replacement in order to coordinate timely access to care and ensure patients’ needs are met at care transitions. This position will facilitate communication between patients, families and members of the healthcare team; advocate for individual needs of the patient; provide evidence-supported education and/or connect patients to other members of the healthcare team, as required; and support data collection and reporting related to patient and program outcomes.
Responsibilities
- Acts as primary contact and liaison between patients, families and hospital and/or community resources.
- Builds effective working relationships with patients, families and community partners.
- Uses appropriate mechanisms to locate and access current and relevant information about the patient’s care plan.
- Engages patients and families to discuss care options and patient preferences and needs.
- Uses a patient centered approach to identify factors that might present barriers to care across the total joint replacement care continuum.
- Advocates for the individual needs of patients and supports patient choice in health care decision-making.
- Ensures patients and families have information and resources needed to make informed decisions and be active participants in their care across the care continuum, especially at care transitions.
- Connects patients to healthcare team and/or other resources, as required.
- Supports patients to take ownership of their care throughout joint replacement journey.
- Documents and maintains accurate records to support ongoing evaluation of patient and program outcomes.
- Facilitates and/or supports the collection of patient-level administrative and patient-reported outcome data, including Patient Reported Outcomes Measures (PROMs) and additional mandatory reporting requirements, as needed.
- Submits data reporting related to patients undergoing total joint replacement and additional program outcomes, as required.
- Track patients across the TRJ care continuum.
- Work with finance/health records to approve and track invoices from community partners.
- Coordinate the Patient and Family Advisory Committee, all associated meetings and related initiatives/projects.
- Work closely with the Director, and Managers to implement Surgical Program strategic objectives.
- Assist with other program priority initiatives or projects in collaboration with leadership team.
- Develops professional relationships with healthcare team members and provides information about patient navigator role and scope.
- Seeks and maintains current information about available resources for patients and families, in both the acute care setting and community.
- Assists in promoting and sustaining continuous quality improvement initiatives to drive change.
- Communicates regularly with healthcare team to collaboratively improve navigation processes.
- Other duties as assigned.
Qualifications
- Degree in a health related field
- Regulated Health Professional and Member of respective College in good standing, i.e. College of Nurses of Ontario, College of Physiotherapy
- Healthcare professional with knowledge, experience and expertise working with patients with musculoskeletal diagnoses; specifically total joint replacement.
- Minimum of 3 years’ experience working with patients on the total joint replacement care continuum preferred.
- Direct work experience in project management/event coordination
- Demonstrated success in project delivery and execution of project management methods.
- Experience using excel and electronic documentation software.
- Experience with communications, writing/editing and/or graphics.
- Experience with collection, tracking and submission of data.
- Knowledge of QBPs and ICD coding an asset.
Skills & Abilities
- Ability to work independently and in collaboration with the inter-professional team to deliver quality patient and family centred care.
- Excellent communication skills and demonstrated ability to communicate effectively with patients, families and colleagues.
- Excellent interpersonal and customer service skills.
- Demonstrated ability in building and maintaining relationships.
- Demonstrated sensitivity and responsiveness to diverse patient populations.
- Ability to exercise discretion and confidentiality.
- Proven organizational skills.
- Problem-solving skills with the ability to negotiate the resolution of conflicts.
- Comfortable using virtual, electronic and personal communication platforms.
- Knowledge of continuum of care for patients undergoing total joint replacement.
- Knowledge of best practices and care pathways for patients undergoing total joint replacement, including Rehabilitative Care Alliance Frameworks.
- Ability to easily convey information to patients and families about their care, including best practice frameworks.
Windsor Regional Hospital is an equal opportunity employer. In accordance with the Accessibility for Ontarians with Disabilities Act, 2005, upon request, accommodation will be provided by WRH throughout the recruitment, selection and/or assessment process to applicants with disabilities. 
