SUMMARY

Are you passionate about improving the health and mental health outcomes of Indigenous peoples by providing culturally appropriate and safe care? Do you have experience with health system navigation and discharge planning? Grand Council Treaty #3 is currently hiring an Indigenous Care Coordinator (ICC) in partnership with Thunder Bay Regional Health Sciences Centre (TBRHSC).
The Indigenous Care Coordinator (ICC) is based in TBRHSC and reports to the Manager of Health Policy, at Grand Council Treaty #3. The ICC will work as part of an interprofessional team with one other Treaty 3 ICC and ICCs who report to Anishnawbe Mushkiki. The ICC will be part of TBRHSC Circle of Care Team under the supervision of the TBRHSC’s Manager, Indigenous Collaboration, Equity & Inclusion.
The ICC is responsible for providing a range of health and mental health navigation, advocacy, discharge planning and supports services to Indigenous peoples accessing health and mental health services at TBRHSC.
The goal of the program is to improve equitable access to care for Indigenous patients and support their return home through rigorous discharge planning processes and supports that leverage community/region-based services that are culturally appropriate and safe. The ICC will work with local communities to support the smooth transition of patients back to their homes as appropriate.
The ICC will primarily be responsible and accountable for care coordination in the Grand Council Treaty #3 territory area; however, the position will work with other ICCs to support continuous coverage and manageable workloads. Each ICC will be a specialist of their area as well as generalists of services available for Indigenous people throughout northwestern Ontario.
Grand Council Treaty #3 and the TBRHSC are committed to delivering healthcare in a manner that is consistent with Patient and Family Centered Care. Applicants are required to have demonstrated knowledge, understanding and commitment to this care philosophy.

QUALIFICATIONS:

Essential Requirements:

• Registered Practical Nurse (RPN) Diploma* or Registered Nurse (RN) Baccalaureate* (unencumbered registration with the College of Nurses of Ontario (CNO)*), or Master of Social Work (unencumbered registration with the Ontario College of Social Workers and Social Service Workers (OCSWSSW))
• Knowledge and understanding of CNO Standards of Practice, or OCSWSSW Standards of Practice, as
• Experience working with Indigenous peoples and communities and providing culturally safe and patient-centered care.
• Proven ability to build relationships and work as a member of an interprofessional
• Excellent interpersonal and communication skills include the ability to provide constructive feedback and resolve conflicts.
• Excellent documentation/written skills
• Working knowledge of the provincial and federal health care systems as it pertains to Indigenous
• Demonstrated ability to work under pressure and manage competing work
• Knowledge of and experience with case management
• Consideration will be made for new nursing graduates awaiting registration exam

Assets:

• Fluent in Ojibwe and/or Oji Cree
• Demonstrated discharge planning
• Knowledge of the local and regional mental health and addictions resources and availability, community services and supports.
• Demonstrated sound clinical knowledge and experience in home care and/or community-based service delivery.
• Experience as a liaison between the Hospital and local community organizations in order to meet the needs of Indigenous patients/clients.
• Knowledge of team-building principles and interprofessional collaboration

Education:

• Provide or connect individuals and their families with educational materials and resources (e.g. understanding their health needs and treatments, community resources, understanding provincial and federal health systems).
• Serve as an operational resource to interprofessional team in the management of discharges by educating the interprofessional team regarding the discharge planning process and availability of community / regional services and supports

Reporting to Grand Council Treaty #3’s Manager of Health Policy and under the supervision of the TBRHSC’s Manager, Indigenous Collaboration, Equity & Inclusion and in accordance with Hospital policies, standards and procedures, the ICC is responsible for:

Planning/Coordinating & Supports:

• Facilitate a patient-centered discharge plan with the physician / health care practitioner (responsible for recommending discharge and any follow-up requirements), patient, family/significant others, and interprofessional team.
• Receive and process referrals and inquiries and provide clear and accurate information on available community-based services to support patients in accessing and optimizing the available services and
• Participate in bed rounds to support patients, nursing staff and interprofessional team to develop appropriate plans of care and discharge plans.
• Coordinate case conferences and trial discharges for complex patient
• Support individuals and families to make necessary arrangements for assisted living, respite, and/or placement of names on waiting lists for facility care.
• Liaise with service providers and suppliers to arrange and authorize necessary services, equipment and devices, medical supplies, and transportation.
• Facilitate referrals to home and community care for alternative level of care and supportive resources (e.g. holistic healing and wellness services, mental health and addictions programs, Joseph’s Care Group programs and other community-based organizations, programs and services).
• Provide advocacy support for patients and their families/support systems as required to support equitable access to quality care.
• Coordinate with psychiatrists and mental health physicians / specialists to support the needs of Indigenous patients with mental health and addictions issues, including developing an appropriate plan of care and discharge and aftercare plan.

Organizational Responsibilities:

• Attend quarterly meetings with Grand Council Treaty #3 management to report back on program
• Participate in Grand Council Treaty #3 and TBRHSC-led training, as relevant /
• Propose changes within the Hospital that would improve the quality of service to Indigenous patients and their families.
• Apply Indigenous culture, values, traditions and teachings into programming / operations where
• Assist and support the development of specific policies or protocols for Grand Council Treaty #3 and TBRHSC to improve access and provision of culturally appropriate and safe services for Indigenous peoples.

Leadership:

• Foster intra/interprofessional collaborative relationships through respectful communication and knowledge of all team members’ roles and responsibilities.
• Facilitate conflict resolution and critical thinking among team
• Advise/assist the patient interprofessional team in specific project activities related to patient flow and implementation of evidence-based/best practices.

Communication:

• Practice excellent interpersonal communication techniques with internal and external partners/stakeholders to achieve efficient patient flow and effective transitions in
• Document discharge plan as part of comprehensive plan of
• Participate in community outreach activities to promote the
• Communicate effectively with patients, families, and/or communities throughout patient journey of
• Develop and maintain collaborative working relationships with other Indigenous Care Coordinators, leaders and health care groups within the community and region to ensure consistency of planning to meet patient needs.
• If able, provide Indigenous language interpretation services as needed to support the accurate transmission of health care information to patients and their families/ support (If unable, work with Indigenous interpreters.)

Education:

• Provide or connect individuals and their families with educational materials and resources (e.g. understanding their health needs and treatments, community resources, understanding provincial and federal health systems).
• Serve as an operational resource to interprofessional team in the management of discharges by educating the interprofessional team regarding the discharge planning process and availability of community / regional services and supports.

Quality & Risk Management:

• Provide insights to the interprofessional team and hospital staff on providing culturally safe and appropriate care.
• Assist in evaluation of patient care outcomes through various audits, chart reviews or other data collection methods.
• Assist with quality/process improvement initiatives and evaluation of ICC
• Assist with timely response of safety reports and patient compliments and
• Identify and report risk management issues related to practice, process or patient care