In accordance with the Purpose, Vision, Values and Coast Salish Teachings, and strategic direction of PHSA, safety, including both patient and employee safety, is a priority and a responsibility shared by everyone at PHSA. As such, the requirement to continuously improve quality and safety is inherent in all aspects of this position.

The Care Coordinator works collaboratively as part of an interprofessional team to provide advanced psycho-social assessments and comprehensive counselling and coordination of services to patients and their families whose children have complex care needs. The Care Coordinator performs professional social work services with a focus on advocating for patients and supporting coordination of services by navigating and creating new pathways of care, and bridging gaps across systems based on individual and specific patient needs. The Care Coordinator participates in on-going service planning, program development, evaluation and quality improvement activities to achieve excellence in client care and also supports capacity building among patients and families, hospital services and community partners. The Care Coordinator utilizes advanced psycho-social assessments to identify the patient and family needs and goals and to support the coordination of a Collaborative Plan of Care.  The Care Coordinator coordinates the continuity of care for patients within the inter-professional treatment team and plays a central role as liaison with community agencies and resources throughout BC and applies advanced knowledge, skill and clinical experience in facilitating communication and decision making around patient care and influencing change. The Care Coordinator promotes family-centered care within BC Children’s Hospital and Sunny Hill Centre for Children and the community.

1. Provides advanced psycho-social assessments for the designated client population by providing intake and family needs assessment, initiating a plan of care which includes the goals and needs identified by parent/caregiver, and other areas as suggested by the comprehensive intake assessment, utilizing teleconferencing to include health care professionals in care planning alongside patients and families around the province.
2. Collaborates and assists within the disciplinary team at BCCH/SHHC by determining gaps with patient and family needs, navigating beyond our own systems and troubleshoot when and how to integrate with other community resources, creating new pathways of care, bridging gaps across systems and linking in with other system resources (such as MCFD and community resources) to advocate for patient needs and secure clinical services for the patient and family.
3. Establishes and maintains effective collaborative and constructive liaison relationships with a variety of individuals and groups, including patients and families, community primary care physicians and pediatricians, community mental health providers, MCFD social workers, schools, hospitals and other agencies, in order to coordinate services.
4. Advocates for the patient and their family or caregiver for resources within the hospital and the community by assessing the financial and other psychosocial needs and works in coordination with community resources to meet these needs.
5. Provides counselling and psychoeducation to families and other relevant caregivers to understand the nature of their concerns and to facilitate change in coping style, behavior, feelings and adaptive responses to adverse life events. Utilizes parent coaching to promote capacity building skills.
6. Makes recommendations for program/service and clinical practice guidelines planning and development as part of a multidisciplinary team.
7. Maintains up-to-date knowledge on research and national and international best practices in care coordination, healthcare leadership and social work practice for children and youth with multiple and complex developmental and behavioral needs. Maintains knowledge of relevant legislation including the Child and Family Services Act, Infants Consent Act, Freedom of Privacy and Information Act and the Mental Health Act.
8. Promotes patient and family centered care by participating in relevant committee work within the Social Work discipline, specialized program, hospital-setting, and/or continuum of health care.
9. Performs administrative tasks by maintaining clinical documentation, progress notes, workload statistics and updating health records in accordance with established standards.
10. Initiates and participates in psychosocial research by methods such as collaborating with members of the interprofessional team, conducting literature searches and planning forums, and implementing appropriate evidence based research outcomes into strategic planning and professional practice.
11. Supervises Masters level social work students on practicum within the program by performing duties such as demonstrating and explaining procedures and processes and providing input regarding progress.  Provides students with the opportunity to observe and take an active role in care coordination and social work practice with patients and their families.
12. Performs other related duties as assigned

Education, Training and Experience

• Master’s Degree in Social Work from an accredited School of Social Work.
• Minimum 3 years’ experience specifically providing assessment, parent or supportive coaching and care coordination both within Hospital outpatient settings and in the community, with families of children with complex developmental or neuromotor needs or equivalent combination of education, training and experience.
• Demonstrated knowledge, understanding and use of leadership approaches and skills including communications and relationship building.
• Current full registration with the British Columbia College of Social Workers.

Skills and Abilities

• Comprehensive knowledge of Social Work theory and practice.
• Knowledge of mental health and complex developmental behavioural or neuromotor conditions.
• Knowledge of the range of service options available for the designated client population both within the hospital and community setting.
• Knowledge of solutions and strategies to reduce various barriers to care for the designated client population.
• Knowledge of and commitment to strengths-based, family-centred practice.
• Comprehensive knowledge and demonstrated ability to apply care coordination principles and ability to advocate for families as they navigate the health care system.
• Demonstrated ability to establish and maintain supportive, trusting and professional relationships with clients and their support group.
• Demonstrated listening and information seeking skills that promotes communication and leads to a co-operative approach to goal setting and problem solving with the family and within a multidisciplinary setting.
• Demonstrated ability to conduct social and psychosocial assessments, and perform a range of needs assessments with both individuals/groups.
• Demonstrated ability to apply coaching or motivational interviewing techniques with families.
• Demonstrated ability to work both independently and collaboratively as a member of a multidisciplinary team.
• Demonstrated ability to prepare and maintain a variety of charts, records and reports. 
• Demonstrated ability to communicate effectively, both verbally and in writing. 
• Demonstrated ability to organize and prioritize workload and adapt to a changing team.
• Demonstrated skills in program development and building partnerships among allied services providers and community partners.
• Working knowledge of quality improvement and research processes and methodology.
• Broad knowledge of psychotherapeutic, counseling skills and clinical practice models.
• Broad knowledge of psychopharmacology (indications and side-effects).
• Broad knowledge of other health disciplines and their role in healthcare.
• Broad knowledge of legislation and government policies and procedures that relate to the client.
• Demonstrated ability to apply systems theory to practice in Social Work assessment and intervention.
• Demonstrated ability to understand and influence group and inter-group processes, decision making and problem solving.
• Demonstrated ability to problem solve, adjust to new or unexpected events and deal effectively with conflict situations.
• Demonstrated ability to teach Social Work students and other team members both formally and informally.
• Physical ability to perform the duties of the position.
• Basic computer literacy to operate a computerized client care information system and word processing, spreadsheet, Internet and e-mail software.