104R2-26-3 Indigenous Transitions Facilitator

Six Nations•Ohsweken, ON

63d•CA$70,400 - CA$88,000•Hybrid

About The Position

The Indigenous Transitions Facilitator reports to and works under the direction and supervision of the Home and Community Care Manager, the Senior Manager of Primary and Clinical Care and the Director of Wellbeing. This role assists the Wellbeing Department in researching, developing, educating, and creating strategies for improved discharges for Indigenous people from hospital to home. The facilitator serves as the initial point of contact for community members being discharged to services on Six Nations. The position involves managing a caseload of clients in the hospital system awaiting discharge, aiding them with system navigation, coordinating continuity of care, collaborating with care partners, and ensuring seamless transitions. The role aims to strengthen comprehensive individualized services, engage caregivers in care plan development, and determine necessary education or training for clients upon discharge. The facilitator will transfer clients to the appropriate Home and Community Care Case Manager post-discharge.

Requirements

Bachelor’s or Master’s degree in Nursing, Occupational Health or Social Work
Minimum of 2 years’ experience working in a hospital setting that includes case management, system navigation, community resources
Knowledge of relevant legislation, including the Excellent Care for All Act (ECFAA), Freedom of Information and Privacy Protection Act (FIPPA), Personal Health Information Act (PHIPA), Health Care Consent Act (HCCA), Fixing Long Term Care Act (FLTCA)
Must have First Aid, CPR and WHMIS
Computer skills in Microsoft Office, MS Word and Excel.
Must be familiar with relevant local and area services, hospital or community-based case management and health resources.
Must be familiar with government funding and legislation related to public services
Good communication and public relations skills both verbal and written
Works well as part of a multi-disciplinary team setting
Demonstrates the ability to understand the importance of confidentiality and ability to work with tact and discretion
Demonstrated problem solving and critical thinking skills
Can function independently as well as part of a team
Must have a clean criminal record check and vulnerable sector screening
Must have an insured vehicle and a Class “G” driver’s license.

Nice To Haves

Experience with EMR systems, such as PS Suites and Clinical Connect, would be considered an asset.
Knowledge about local culture and traditions is preferred
Knowledge of or ability to speak an Indigenous language is an asset.

Responsibilities

Assisting the Wellbeing Department in researching, developing, educating, and creating strategies for improved discharges for Indigenous people from hospital to home.
Serving as the first point of contact for community members being discharged to services on Six Nations.
Managing a caseload of clients in the hospital system awaiting discharge.
Assisting clients with system navigation and coordinating proactive continuity of care.
Collaborating on referrals within the circle of care partners.
Assisting clients with seamless care transitions and provider intersection.
Strengthening linkages in the delivery of comprehensive individualized wrap-around services.
Ensuring the early engagement of client-identified caregivers in the development of their care plan.
Determining any education or training required to support the client in their living arrangement of choice upon discharge from a regional facility.
Transferring the client over to the appropriate Home and Community Care Case Manager upon discharge.
Assessing current discharge protocols, staff, and programs involved in discharge planning.
Building relationships with and meeting regularly with administration, medical and nursing staff, hospitals, discharge planners, social workers, patient navigators, and Ontario Health at Home.
Assessing outcomes of the current discharge plan.
Determining gaps in service and strategizing improvements to discharge planning.
Developing and implementing client service plans for the delivery of high-quality service and discharge planning.
Determining the appropriate case manager for handover upon discharge.
Following established reporting procedures as laid out by the Six Nations Department of Wellbeing.
Reporting on progress, failed discharges, and outcomes of services by hospital and community as it relates to discharge.
Ensuring that institutions are aware of the resources at SNGR and in other Indigenous communities and agencies and how to access them.
Providing information and coordinating regular meetings for discharge planning.
Assisting staff, clients, and families when necessary to promote case conferencing.
Developing and implementing policies and procedures for discharge planning.
Regularly reviewing client care and discharge outcomes to ensure the right care is delivered to the right client at the right time.
Considering client safety and liability issues.
Working with existing staff, administration, medical and nursing staff, hospitals, discharge planners, social workers, patient navigators, and Ontario Health at Home discharge planners to develop protocols, resources, and increased collaboration between agencies.
Ensuring Care Plans and Service Plans are appropriate and resources are available to clients and staff.
Assisting clients in providing information, awareness, and direction to create self-determination, responsibility, independence, and autonomy in relation to their own care.
Attending regular meetings to allow open communication and dissemination of information.
Ensuring a successful handover to the Home and Community Care or Palliative Care Case Manager.
Performing other job-related duties as may reasonably be required by the Manager of the Home and Community Care Program.
Providing support for the Six Nations Emergency Measures Plan by ensuring awareness of the Emergency Measures Plan and assistance as instructed by the Director of Wellbeing.