Nurse Navigator, Respiratory Care

Job Description

Title: Nurse Navigator, Respiratory Care

Reports to: Manager, Primary Care

Position Type: Full-Time, Permanent (1.0 FTE 35 hrs/week) – Flexible options available

Salary: $35.96 – $42.30/hour

Vacancy Status: New Vacancy

Location: Kingston

Position Summary

The Nurse Navigator plays a key role in the coordination and delivery of comprehensive, patient-centered care and helps to manage complex health conditions, assess and educate patients and their families or caregivers about lung health (i.e. asthma, COPD, etc.) and employs interventions for health education. Embedded within a multi-disciplinary team across the Kingston Community Health Centres (KCHC), Kingston Health Sciences Centre (KHSC) and clinicians within the FLA-OHT region, the Educator supports care transitions, facilitates access to evidence-based services, provides lung health education, and fosters self-management. The Nurse Navigator plays a pivotal role within a Nurse Navigation framework, supporting centralized triage care, prioritization of care, rapid access programming, and ongoing care navigation with, all with a strong focus on reducing avoidable hospitalizations.

Key Responsibilities

Care Coordination & System Navigation

• Centralize triage of referrals (self-referral, eReferral, ED notifications) and direct patients to appropriate services.
• Oversee and implement rapid access clinics for patients with acute exacerbations or high risk of (re)admission.
• Track and manage a panel of COPD patients, ensuring evidence-based care is being received and documented.
• Facilitate interagency and interprofessional collaboration, including with hospitals, home care, social workers, and public health.
• Maintain a current inventory of regional lung health services and community resources.
• Support patients in addressing social determinants of health affecting care (transportation, housing, financial stressors).

Client Care and Clinical Navigation

• Perform therapeutic interventions including oxygen titration, medication reviews, and smoking cessation counselling.
• Develop individualized COPD Action Plans and self-management goals in collaboration with patients and interprofessional teams.
• Provide education and support on inhaler techniques, exacerbation recognition, medication adherence, and symptom monitoring.
• Ensure continuity of care post-discharge by coordinating follow-up with primary care providers, specialists, or virtual/walk-in clinics.
• Serve as the primary contact for patients throughout their lung health journey.
• Participate in group and individual respiratory rehabilitation sessions and programming.

Education, Capacity Building & Community Engagement

• Provide COPD education to patients, caregivers, and healthcare teams using standardized and evidence-based tools.
• Promote public awareness of lung health and available supports within the community.

Administration

• Document all patient interactions using KCHC's EMR and comply with Ontario Health and internal documentation standards, including submission of PROM and PREM data to the ISAAC database.
• Participate in program planning, quality improvement, data collection, and research initiatives as required.
• Collaborate with the FLA OHT Integrated Care Pathways team and meet with stakeholders from other organizations to support regional COPD pathway delivery.
• Maintain a database of all patients seen and triaged, with tracking of gaps in care and their completion.

Organizational Responsibilities

• Comply with all relevant legislation and KCHC policies, including privacy laws
• Commits to acquiring an understanding of the importance of trauma responsiveness and the impact of Adverse Childhood Experiences (ACEs)
• Commits to demonstrating an ongoing commitment to Equity, Diversity, Inclusion, Indigenization and Accessibility (EDIIA) by representing the diverse nature of our communities, promoting and practicing inclusion
• Supports consistent application and development of KCHC policies and procedures
• Supports KCHC's student and volunteer placement programs
• Promotes awareness of and participation in KCHC activities
• Demonstrated commitment to continuous learning and quality improvement
• On occasion, perform other temporary duties as required

Basic Education and Experience Requirements

• Registered Nurse, in good standing with the College of Nurses of Ontario
• Three plus years nursing experience in a hospital or community setting or combination of community and hospital/public health settings
• Experience and understanding of marginalized communities and health needs

Knowledge, Skills and Abilities

• Health Care professionals with experience in lung health and COPD Care considered an asset
• Ability to provide welcoming, inclusive, non-judgmental service; sensitive to cultural and social barriers that clientele may be facing
• Knowledge of privacy legislation as it relates to healthcare and private documents
• Demonstrated ability to work in a multi-disciplinary setting
• Proficiency in typing, the use of computers and various software applications, database management experience an asset
• Strong interpersonal (oral and written) and problem-solving skills; a commitment to teamwork
• Excellent organizational skills, above average attention to detail, and ability to multi-task in a fast-paced environment

Other Requirements

• Current and satisfactory Criminal and Vulnerable Persons Check
• Up to date Immunization Record
• Access to a vehicle and valid driver's license

As a registered professional, to abide by and be accountable to the ethics and standards set out by the relevant regulatory body of the profession. All KCHC staff have a duty to understand and follow KCHC policies, uphold high ethical and professional standards, and maintain confidentiality and privacy, using tact and good judgment in all dealings with other staff and clients.

At Kingston Community Health Centres (KCHC), we understand that the work of Equity, Diversity, Inclusion, Indigeneity, and Accessibility (EDIIA) is ongoing. We are dedicated to being accountable, transparent, and responsive to the holistic needs of the communities we serve. We will continue to listen, learn, and take meaningful action to ensure that our policies, practices, and services create an environment where everyone, regardless of their identity or circumstances, can thrive.

We actively encourage individuals from all backgrounds, including but not limited to women, racialized groups, Indigenous peoples, persons with disabilities, and those who identify as members of the 2SLGBTQI+ communities, to apply to KCHC. Our commitment to EDIIA is a living practice, one that evolves as we grow and learn together. We pledge to contribute to building a system that is equitable, diverse, inclusive, accessible, and welcoming for all.

KCHC is an equal opportunity employer, respecting and embracing the needs and diversity of our employees. If you require accommodation to fully participate in the hiring process, please notify Human Resources.

Kingston Community Health Centres, 263 Weller Ave. Kingston ON, K7K 2V4