Barrie Family Medical Health Team jobs in Barrie, ON

Job Description:

The Indigenous Transitions Facilitator role aligns with strategic direction from Indigenous Services Canada, and with the foundational strategic priorities identified in the Letters of Relationship between RVH and Barrie and Area Native Advisory Circle – Indigenous Health Circle (BANAC - IHC).

The Indigenous Transitions Facilitator (ITF) is a key member of the interdisciplinary team responsible for supporting timely and safe discharges of Indigenous patients from hospital to home or the most appropriate community setting. This role combines effective clinical resource management with patient navigation, ensuring that goals of care are met while facilitating equitable access and culturally safe care.

Responsibilities:

• Develop and facilitate individualized care planning and discharge processes to optimize patient flow across the organization
• Serve as the primary point of contact for Indigenous patients and families during hospital discharge planning
• Provide education, navigation, and support to patients and families around home care services, financial resources, and available community supports
• Medication reconciliation and health teaching
• Assess patient eligibility for homecare and community programs based on established criteria
• Collaborate with interdisciplinary teams to determine estimated discharge dates and coordinate community supports
• Liaise with external providers and system partners, including Home and Community Care services such Ontario Health atHome and First Nation Homecare Programs, Jordan’s Principle and Non-Insured Health Benefits (NIHB) to develop and implement comprehensive plans of care that meet post-acute needs
• Contribute to the improvement of discharge processes, flow strategies, and resource utilization throughout the organization

Qualifications:

Education:

• Registered Health Professional with current and unencumbered registration with the College of Nurses of Ontario (CNO) or relevant regulatory body
• Baccalaureate degree in Nursing or a health-related discipline required
• Current Basic Life Support (BLS) certification required

Experience:

• Minimum 5 years of clinical experience in diverse settings (e.g., medical/surgical, emergency, and/or community) preferred
• Demonstrated experience in discharge planning, case management, and utilization management aligning with Health Quality Ontario’s Transitions Between Hospital and Home, Care for People of All Ages Quality Standard
• Strong knowledge of community-based resources, supports, and systems
• Experience working with vulnerable and medically complex patient populations

Competencies:

• Lived experience within an Indigenous community, combined with knowledge of Indigenous cultural practices
• Experience and understanding of First Nation, Métis and Inuit history, culture, health determinants, and perspectives on health and well-being
• Strong interpersonal, communication, and collaboration skills with the ability to foster trust with patients, families, and interprofessional teams
• Commitment to providing culturally safe, trauma-informed, patient- and family-centered care
• Proven organizational and problem-solving skills with the ability to prioritize and multi-task in a fast-paced environment
• Effective critical thinking and clinical judgment in decision-making and resource coordination
• Ability to adapt to change and take initiative on projects with minimal supervision

Other:

• Proficiency in Microsoft Office and Outlook; working knowledge of Meditech and financial/healthcare reporting systems an asset
• Demonstrated alignment with RVH values: Team up, Be kind, Do great things, Inspire trust, Be bold
• Upholds professional standards, patient safety, and contributes to a healthy work environment in accordance with health and safety legislation

Exhibits the core values of Royal Victoria Regional Health Centre: Inspire Trust, Be Kind, Be Bold, Do Great Things, Team Up.