System Navigator

**Title**:System Navigator - Integrated Palliative Care Program (Contract - 6 months)

**Hours**:Full-time, 37.5 hours per week

**Duration**:6 months (possibility of extension)

**About the Integrated Palliative Care Outreach Team**:
The Burlington Integrated Palliative Care Outreach Team is a multi-organization partnership that aims to facilitate seamless care pathways for those requiring palliative care services in and around the Burlington Community. The interdisciplinary team includes: Nurse Practitioner, Psychosocial Grief and Bereavement Clinician, Palliative Physician(s), and System Navigator.

**Position Summary**:
The System Navigator is a newly created dynamic role that will further the goals of this partnership. This role will support the work of the Burlington Integrated Palliative Care Outreach Team (PCOT). PCOT is a group of specialist providers from multiple organizations who practice as an interprofessional team. The PCOT team have shared accountability with primary care for patients requiring a palliative approach to care. The team is a source of expert advice and consultation that provide specialist palliative care services for patients with complex needs mainly in their homes or place of residence. The services available are: pain & symptom management support, psychosocial-spiritual support, bereavement care, professional mentorship & coaching, and palliative system navigation for patients and their families/caregivers.

Carpenter Hospice is the host organization for this position. We are an 11-bed home in the heart of Burlington that offers residential and community care to individuals living with a palliative illness and their family/caregivers. It is an exciting time to be joining Carpenter Hospice as we expand our community services in Burlington and surrounding areas.

**Position Responsibilities**:

- Applies the principles of relationship centered care and care coordination
- Acts as the initial contact for all incoming calls from patients, families, community agencies and physicians for PCOT
- Initiates and enters all referrals to PCOT into the electronic health record system
- May meet referred clients in person/in home (when clinically relevant) to understand needs, concerns, and priorities
- Reviews existing assessments and may conduct a further assessment to ensure a comprehensive understanding of client/family
- Prioritizes medical and psychosocial needs in collaboration with other members of PCOT
- Provides education and information about care options and resources
- Facilitates team communication, systems advocacy and navigates barriers to care families may experience
- Completes follow-up calls to patients and/or families to ensure care needs have been met
- Inventories relevant community services, liaising with external stakeholders and referral sources
- Prepares reports and participates in all team meetings and rounds
- Maintains and updates all patients’ medical records and files including patient and family risk indicators
- Data collection for program evaluation and quality improvement
- Uses critical thinking skills to escalate more urgent patient care needs
- Actively seeks data and illuminates opportunities to improve the patient experience and support systems change
- Provide coverage for the Intake Coordinator as needed
- Other duties as required

**THE IDEAL CANDIDATE**:

- Regulated Health Professional (RHP) with current membership within the relevant Ontario regulatory body. Preference will be given to RN, RPN applicants, but all RHPs will be considered
- Previous experience working palliative care required, experience in outpatient palliative care preferred
- Knowledge of pain and symptom management
- Demonstrated experience with case management and care planning
- Demonstrated ability to work independently and as part of an interprofessional team
- Excellent interpersonal and conflict resolution skills
- Knowledge of support services and resources in the community
- Excellent written and verbal communication skills and organizational skills to successfully manage multiple priorities in a complex work environment.
- Knowledge of Word, Excel and OSCR
- Demonstrated capacity integrating Equity, Diversity, and Inclusion (EDI) principles and anti-oppressive practices

**OTHER REQUIREMENTS**:

- Ability to work flexible hours including evening hours and weekends to meet the needs of clients and families.
- Ability and means to travel as needed.
- Required to provide a satisfactory current Criminal Reference Check (CPIC) including a Vulnerable Sector Check prior to hire.

At Carpenter Hospice, we are committed to fostering an inclusive and accessible environment. We are dedicated to building a workforce that reflects the diversity of the community. Should you require accommodation during any phase of the recruitment process, please indicate this in your cover letter. For any assistance, please contact the Human Resource Department at 905-631-9994 extension 144.