Summary: 

The Nurse Navigator works with clients and families to facilitate discharge planning and safe independent living. The Nurse Navigator links Anishinabek people with available health services to assist with remaining in the place that is most appropriate to their needs and safety. Services will be offered on a short-term basis up to 12 sessions. Services will be client centered. 

Job Duties:

1. Collaborate with elderly clients (with complex care needs) and health care services to facilitate discharge planning and safe independent living. Case management to assist elders with connecting to available health services.

• Support client and family in understanding diagnoses, impacts, treatment and discharge planning. 

• Assist the client in identifying care plan goals. 

• Collaborate with acute care discharge team to ensure post-hospital care is in place. 

• Support the circle of care in meeting the health care needs of clients and their families.

• Attend hospital rounds to support discharge planning.

• Support cultural competency in collaborative care planning process. 

2. Advocate for clients to reside in the place that is most appropriate to ensure their safety and well-being. 

• Assess and refer clients to appropriate community services. 

• Participate and support client and family case conferences with the circle of care for complex cases. 

• Assist clients facing language and cultural barriers to improve access to care. 

• Expedite/assist/support referrals to specialists and rehabilitation services. 

3. Plan and coordinate relevant workshops for health care providers. 

• Support continuing education in the communities in relation to elder care. 

4. Perform administrative duties in support of the organization’s goals and objectives

• Prepare statistical reports 

• Schedule appointments and prepare work plans to effectively meet client and community needs

• Complete client medical records within the electronic database (2 business days). 

5. Perform other duties as assigned within the scope of the position

• Engage in professional development to maintain current skills and knowledge regarding the scope of the position

• Assist in the development and implementation of the organization’s quality improvement initiatives

• Network with partner agencies to improve practices, enhance services and move forward shared initiatives relevant to the position

Requirements:

Mandatory

• Current registration in good standing with the College of Nurses of Ontario

• Three to five years experience working in nursing

• One to three years experience working with the elderly

• Current CPR C and First Aid Certification

• Valid Class G driver’s license and have access to a vehicle

• Current Criminal Record and Vulnerable Sector check. 

Preferred

• BSCN

• Membership with the Registered Nurses Association of Ontario 

• Experience working in First Nation communities, knowledge of traditions and customs

• Experience working within an electronic medical record system

Knowledge

• Strong knowledge of senior health needs

• Knowledge of the First Nation communities of Manitoulin Island

• Knowledge of the service providers within the Manitoulin Island catchment area

• Knowledge of First Nation health issues

• Understanding and sensitivity for the Anishinaabe culture

Skills

• Skilled in interpersonal relations

• Strong time management skills

• Excellent verbal and written communication skills

• Proficiency in Microsoft Office

Ability

• Strong ability to prioritize, plan, organize and schedule

• Ability to work with minimal supervision

• Ability to speak Anishinaabemowin is an asset

Work Conditions:

• Occasional exposure to biohazards and infectious diseases

• Frequent interruptions within the office environment

• Frequent long-distance travel required

• Frequent sitting required

• Services are delivered within seven First Nation clinics and on-site

• May require use of interpreters for clients where Ojibwe is their first language