Indigenous Transitions Facilitator – NADMIN 11-26

Job Summary:

The Indigenous Transitions Facilitator plays a key role in supporting seamless care transitions for Indigenous clients by integrating provincial, federal, and community health and social support services across the care continuum. Working within a culturally safe and patient-centered framework, the Facilitator collaborates with healthcare providers, discharge planners, Indigenous organizations, and community partners to improve access to quality care and strengthen health outcomes for individuals, families, and communities across Northwestern Ontario.

Qualifications:

• Registered Nurse (RN) or Registered Practical Nurse (RPN) in good standing with the College of Nurses of Ontario (CNO), OR Social Worker in good standing with the Ontario College of Social Workers and Social Service Workers (OCSWSSW), OR other Allied Health Professional with relevant education and experience.
• Palliative Care for Front Line Workers in First Nations Communities training; Learning Essential Approaches to Palliative and End of Life Care (LEAP) an asset or be willing to attain.
• Minimum two (2) years of experience in healthcare, social services, Indigenous health, community health, or a related field preferred.
• Indigenous cultural competency training (organizational curriculum of choice) preferred.
• Have an equivalent combination of education and experience working in an Indigenous health and/or social service organization, hospital or community-based management, health promotion, public health or social work.
• Awareness of formal patient or service agreements with local indigenous communities/organizations.
• Demonstrated knowledge of system navigation, community resources, and programs that support Indigenous clients and families.
• Excellent communication, interpersonal, and relationship-building skills.
• Strong organizational, problem-solving, and critical thinking abilities.
• Ability to work independently and effectively within an interdisciplinary healthcare team.
• Proficiency with Microsoft Office applications, electronic health records, and other technology systems.

Job Duties:

• Coordinate proactive continuity of care and support seamless transitions between hospital, community, and long-term care services.
• Collaborate with Indigenous clients, families, caregivers, healthcare providers, and community partners to develop individualized care plans.
• Facilitate referrals and navigation of provincial, federal, and Indigenous health and social support programs.
• Support discharge planning and transition processes to promote positive health outcomes.
• Build and maintain strong relationships with Indigenous communities and community-based organizations.
• Advocate for culturally safe, trauma-informed, and patient-centred care.
• Participate in family meetings, care conferences, and interdisciplinary team discussions.
• Maintain accurate documentation within electronic health record systems.
• Monitor and report program outcomes and performance indicators.
• Adhere to organizational policies, safety procedures, infection prevention and control standards, and confidentiality requirements.

Benefits:

• Opportunity to join a growing organization and be a key member of a highly motivated team of Discharge Planners and other health care professionals
• Exceptional pension plan (HOOPP)
• Blue Cross benefits package
• Housing and relocation assistance available