Intake and Navigation Care Coordinator

Overview

Intake and Navigation Care Coordinator -HHP Nurse

WellFort Community Health Services is a values-based, non-profit, multi-service organization committed to reducing barriers to care and improving the health of our communities. We provide services from an equity-focused, trauma-informed, and culturally responsive approach to individuals and families, many of whom have experienced systemic barriers and health inequities.

We prioritize populations who experience barriers to health and accessing services, including newcomers and refugees, people experiencing homelessness, racialized communities, those living with low income, and individuals living with complex mental health, substance use, or chronic conditions.

Homeless Health Program

The Homeless Health Program is a Nurse Practitioner-led initiative that provides essential healthcare services to individuals who are homeless, precariously housed, or transitioning out of homelessness in the Peel Region. We understand the unique challenges faced by those without stable housing, and our goal is to make healthcare accessible, integrated, and responsive.

Our dedicated team includes Nurse Practitioners, Registered Nurses, Registered Practical Nurses, and Personal Support Workers, all working together to ensure our patients receive the care they need, where and when they need it. We remove barriers to care for those facing housing instability and poor health.

The program manages 45 medical beds at the Dundas Street Shelter, providing 24/7 care, as well as daytime mobile primary care services at other shelters and drop-ins across the region.

By providing these services, we help hospitals make the best use of their emergency and acute care resources. Patients who no longer need to stay in the hospital but still require medical support can continue their recovery in a shelter bed with healthcare services. We also offer additional support for people in shelters who may need extra medical attention, helping to prevent unnecessary hospital visits.

Our medical services include:

- Care for chronic conditions like diabetes
- Medication management
- Support for substance withdrawal and pain management
- Wound care
- Mental health services and stabilization
- Monitoring and support after hospital stays

This program ensures that structurally vulnerable populations in our community have access to the care they deserve, improving overall health and wellbeing.

The Intake & Navigation Care Coordinator role leads timely access to care across WellFort programs and sites by coordinating central intake, system navigation, and warm referrals across primary care, mental health and addictions, chronic disease and wellness, and community/social services. Working from a trauma-informed, harm-reduction, and culturally safe approach, the Intake & Navigation Care Coordinator triages and prioritizes clients based on physical and social needs, guided by the social determinants of health (e.g., housing, income, food access, language/immigration, transportation) and aligns response levels and follow-up timeframes with program standards and partner pathways. The role collaborates with interprofessional teams and community partners to deliver coordinated, wraparound care.

Core activities include welcoming clients, completing holistic assessments, developing and updating individualized care plans, facilitating warm handoffs, and routing clients to the appropriate provider or setting at the appropriate time using standardized screening tools and sound judgment.

The successful candidate will bring a deep understanding of the challenges faced by people experiencing marginalization including newcomers, individuals facing homelessness or housing precarity, and other equity-deserving populations and will demonstrate empathy, dignity, and respect in their work.

The Opportunity

Reporting to a Program Manager, the Intake & Navigation Care Coordinator is a core member of our interprofessional team, advancing timely access, coordinated transitions, and continuity of care across programs and sites, in close collaboration with partners to deliver holistic, integrated care.

Responsibilities

- Under the direction/delegation of an authorized clinician, perform specific clinical acts (e.g., specimen collection, vaccine administration) and, as delegated, communicate routine test results and follow-up plans; escalate according to protocol.
- Perform central intake across programs; complete holistic assessments (history, vitals/measurements, screening); triages and prioritizes clients based on their physical and social needs considering the holistic needs of clients including housing, income, food access, language, and transportation; develop individualized prevention/care and self-management plans.
- Coordinate and monitor care-plan delivery; provide ongoing support, follow-up, and case coordination across health, social, and community services, in collaboration with partner organizations.
- Provide health education to clients, families, and groups.
- Maintain accurate, timely EMR documentation (assessments, care plans, transitions, referrals, outcomes); participate in chart/case reviews;
- Contribute to data quality, reporting, and continuous quality improvement (CQI); support protocol, pathway, and tool development.
- Participate in program/service and policy development, implementation, monitoring, and evaluation; coordinate outreach/mobile clinics with internal programs, community organizations, providers, and local stakeholders as needed.
- Participate in case conferences, multidisciplinary meetings, community outreach, and agency awareness initiatives.
- Advocate with and for clients to reduce barriers and ensure fair, dignified access to care and supports; contribute to community education and collaborative strategies.
- Manage clinic readiness operations: maintain/order equipment and supplies; share responsibility for safe handling of medications and vaccines (including cold-chain compliance); make purchases within allocated budget lines and follow procurement controls; assist with operational policies and procedures.
- Maintain current knowledge of relevant government guidelines, acts, and legislation affecting client care and organizational practice.
- Supervise and support students/learners from various disciplines; contribute to orientation and teaching activities with a determinants-of-health lens.
- Participate in applied research and evaluation projects, as appropriate.
- Perform other duties as required to meet program and organizational needs.

Bachelor’s degree in nursing or related health-care field; in good standing with the applicable regulatory college.

- Experience coordinating care with individuals facing barriers to access including equity-deserving populations.
- Demonstrates a strengths-based perspective, recognizing and building on the inherent assets, skills, and resilience of individuals and communities. Focuses on empowerment rather than deficits, fostering dignity, self-determination, and collaborative problem-solving in all interactions.
- Deep appreciation for the challenges faced by people experiencing homelessness and housing precarity, and those impacted by intersecting forms of marginalization.
- Strong understanding of trauma-informed care, harm reduction, and culturally safe practice.
- Experience with care coordination, case management, and system navigation in community-based settings.
- Excellent written and oral communication skills tailored to appropriate literacy levels.
- Knowledge of local health, social, and community service systems and referral pathways.
- Experience working with diverse communities and knowledge of anti-oppressive framework.
- Demonstrated ability to organize workload, respond effectively to unexpected situations, and multitask in a fast-paced environment.
- Valid driver’s license and access to a reliable vehicle.
- Current First Aid/CPR and a clear Vulnerable Sector Check.
- Additional languages relevant to the community are an asset.

Working Environment & Physical Demands

- Work may be mobile and/or site-based across multiple locations and programs including shelters.
- Ability to work flexible hours, including some evenings and Saturdays.
- Exposure to individuals experiencing crisis, complex health conditions, or escalated behaviours.
- Combination of client-facing interactions, outreach activities, and administrative responsibilities.
- Requires flexibility, adaptability, and comfort building longitudinal relationships with clients and collaborating across programs.

Additional Requirements

- Satisfactory Police Records Check and Vulnerable Sector Screening.
- Proof of full COVID-19 vaccination, unless exempt under the Ontario Human Rights Code.

Our Commitment to Equity

WellFort is an inclusive and equitable employer. We encourage applications from members of equity-deserving communities, including but not limited to Indigenous peoples, racialized individuals, 2SLGBTQIA+ persons, persons with disabilities, and people with lived experience of poverty, homelessness, or systemic marginalization.

Compensation package includes health and dental benefits and HOOPP pension benefits. (Based on employment status)

As a condition of employment, new WellFort staff must be fully vaccinated unless they have received an exemption from vaccination under the Human Rights Code. Proof of COVID-19 vaccination status will be required before the first day of work or, proof of religious or medical exemption, if or where applicable.

Fully vaccinated is defined as having received the completed series of an accepted COVID-19 vaccine, as recommended by the Office of the Chief Medical Officer of Health and having received the final dose at least 14 days before your employment start date.

The candidate will be asked to provide WellFort with proof of full vaccination, prior to their employment start date. Acceptable proof is a Ministry of Health Dose Administration Receipt (or such other proof of vaccination that the Province of Ontario sanctions). This can be obtained through the Provincial portal https://covid-19.ontario.ca/get-proof/ (link is external).

The requirement to be fully vaccinated is subject to the Ontario Human Rights Code. If the candidate is unable to vaccinate for a reason protected by the Code, a request for accommodation can be requested and written proof satisfactory to the organization will be required.

#J-18808-Ljbffr