Indigenous Transitions Facilitator - Inclusion

Title: Indigenous Transitions Facilitator

Department: Inclusion (People Services)

Position Number: 50075356

Hours of Work: Full-Time Position, Days

Salary: Class 05 $86,596.77 - $103,915.89 per annum + pension/benefits

Union: Non-Union

Location: Kingston Health Sciences Centre sites

PRIMARY FUNCTION

The Indigenous Transitions Facilitator is responsible for supporting Indigenous patients, families, and caregivers in navigating health and social service systems and accessing coordinated, culturally safer care across the care continuum. As an Indigenous health resource, who works across multiple programs and in the broader community, the Indigenous Transitions Facilitator promotes Indigenous health equity through advocacy, partnership development, and organizational capacity-building in support of culturally safer care and reconciliation.

Working collaboratively with patients, families, caregivers, interdisciplinary care teams, Indigenous communities, and community partners, the Indigenous Transitions Facilitator serves as a bridge between hospital and community services, reducing barriers to care and connecting individuals to comprehensive wraparound supports that address physical, emotional, mental, social, and spiritual needs. Through system navigation, care coordination, transition planning, caregiver engagement, and relationship-building, the role promotes equitable, person-centred care grounded in Indigenous perspectives of health, wellness, and healing.

RESPONSIBILITIES & DUTIES INCLUDE:

Transition Planning

• Respond to referrals from hospital care teams and serve as a key contact for Indigenous patients and families during discharge planning and care transitions.
• Coordinate services that help patients navigate and move safely between hospital, primary care, community services, long-term care, Indigenous health services, and provincial and federal programs.
• Collaborate with patients, families, caregivers, and care teams to develop discharge plans, involving caregivers early to identify education and support needs.
• Support medication reconciliation and help patients and caregivers understand medications, treatment plans, and follow-up care.
• Assess eligibility for home care and community programs, share information on available services, and coordinate with partners such as First Nation Home and Community Care, Jordan's Principle, and Non-Insured Health Benefits (NIHB).
• Maintain timely, accurate documentation in accordance with organizational, professional, privacy, and legislative requirements.
• Contribute to improving discharge planning processes and transition supports across the organization.

Advocacy, Access and Wraparound Supports

• Advocate for equitable access to services and identify barriers related to healthcare, social services, funding, transportation, housing, or other supports.
• Connect patients and families with Indigenous community resources, cultural supports, traditional healing services, Elders, and Knowledge Keepers when requested.
• Help patients access benefits and funding programs, and coordinate supports that address physical, emotional, mental, social, cultural, and spiritual needs.

Relationship Building and Community Partnerships

• Build and maintain positive relationships with Indigenous communities, organizations, Elders, Knowledge Keepers, healthcare providers, and community agencies.
• Act as a link between hospital teams and community partners to strengthen services and support smoother transitions between hospital and community care.

Organizational Consultation and Capacity Building

• Provide guidance to staff and care teams on Indigenous health resources, community services, and culturally safer approaches to care.
• Share knowledge of Indigenous perspectives of health, wellness, and healing, and participate in initiatives that advance Indigenous health equity, culturally safer care, and reconciliation.

Quality Improvement, Reporting and Program Support

• Participate in data collection, reporting, and program evaluation activities.
• Identify service gaps and contribute to quality improvement initiatives, resources, and practices that improve care transitions and outcomes for Indigenous patients and families.
• Support organizational initiatives aligned with Inclusion and the Integrated Inclusion framework.

NOTE - The above duties are representative but are not to be construed as all-inclusive.

BASIC QUALIFICATIONS:

• Post-secondary diploma or degree in nursing, social work, or a related health discipline that meets the educational requirements for registration with the applicable professional regulatory college.
• Current registration in good standing with the applicable Ontario regulatory college (e.g., College of Nurses of Ontario, Ontario College of Social Workers and Social Service Workers, College of Occupational Therapists of Ontario, or College of Registered Psychotherapists of Ontario).
• Minimum three (3) years of recent clinical experience in a healthcare setting, including patient assessment, care coordination, interdisciplinary collaboration, and supporting patients and families with complex needs.
• Lived Indigenous experience is required, with an understanding of Indigenous cultures, traditions, values, and the healthcare needs and barriers facing Indigenous patients, families, and communities.
• Strong clinical assessment, critical thinking, problem-solving, and decision-making skills to identify needs, address barriers to care, and support care planning.
• Knowledge of healthcare systems, community resources, and patient support services, as well as relevant legislation, professional standards, and confidentiality requirements.
• Excellent communication, interdisciplinary collaboration, advocacy, and conflict resolution skills, with the ability to navigate complex situations with empathy, sensitivity, and sound judgement.
• Strong organizational and time management skills, with the ability to manage competing priorities.
• Proficiency with electronic health records, clinical documentation systems, and standard computer applications.
• Satisfactory criminal reference check and vulnerable sector search required.

PHYSICAL REQUIREMENTS:

The applicant must be able to meet the physical demands of this position.

KHSC is located on the ancestral lands and waters of the Anishinaabeg and Haudenosaunee and serves a wider geographical area that encompasses many Indigenous communities including Tyendinaga, Katarokwi, as well as communities within the Weeneebayko Area Health Authority. As we partner in care, discovery, and learning to achieve better health outcomes for our communities, KHSC is committed to actively advocating for and acting upon the Truth and Reconciliation Committee’s Calls to Action on Health.

Unless specifically stated, all job postings are for existing positions at KHSC. KHSC is committed to recruitment practices that support and contribute to building a respectful, diverse and inclusive workplace in compliance with legislation such as the Employment Standards Act and Accessibility for Ontarians with Disabilities Act. We welcome all applications from women, racialized persons, persons with disabilities, Indigenous Peoples, persons in the 2SLGBTQIA+ community, and members of other equity deserving groups.

Kingston Health Sciences Centre may use artificial intelligence systems to assess and screen applicants. All hiring decisions are made in accordance with KHSC policies and applicable employment legislation.

We thank all applicants, but only those selected for next steps will be contacted. Kingston Health Sciences Centre is committed to inclusive and accessible employment practices. If you require an accommodation to fully participate in the hiring process, please notify the Recruitment Team.