140-25-3 Indigenous Transitions Facilitator

Applications will be received by Six Nations of the Grand River and Grand River Employment & Training (GREAT) up until 4:00 p.m. EST, Wednesday, September 3, 2025, for the Indigenous Transitions Facilitator with Home and Community Care, Wellbeing. The Six Nations of the Grand River Application for Employment Form, Job Posting and Job Description are available for printing from the www.greatsn.com website. Online applications accepted through My Job Search. NO LATE APPLICATIONS ACCEPTED.

Applicants from Six Nations and other First Nations will be given preference to deliver programs and services in a First Nations community.

JOB SUMMARY: The Indigenous Transitions Facilitator reports to and works under the direction and supervision of the Home and Community Care Manager, the Senior Manager of Primary and Clinical Care and the Director of Wellbeing.

To assist the Wellbeing Department in researching, developing, educating and developing strategies for improved discharges for Indigenous people from hospital to home.  The Indigenous Transitions Facilitator is the first point of contact for community members being discharged to services on Six Nations.

The Indigenous Patient Facilitator will have a caseload of clients currently in the hospital system awaiting discharge, assisting them with system navigation and coordinating proactive continuity of care, collaborating on referrals within the circle of care partners, assisting them with seamless care transitions and provider intersection.  This role will strengthen linkages in the delivery of comprehensive individualized wrap around services and ensure the early engagement of client identified caregivers in the development of their care plan.  They will also determine any education or training required to support the client in their living arrangement of choice upon discharge from a regional facility.  Upon discharge, the Indigenous Transitions Facilitator will transfer the client over to the appropriate Home and Community Care Case Manager.  

*A competitive compensation package will be offered commensurate with qualifications. *

BASIC QUALIFICATIONS:

• Bachelor’s or Master’s degree in Nursing, Occupational Health or Social Work
• Minimum of 2 years’ experience working in a hospital setting that includes case management, system navigation, community resources
• Knowledge of relevant legislation, including the Excellent Care for All Act (ECFAA), Freedom of Information and Privacy Protection Act (FIPPA), Personal Health Information Act (PHIPA), Health Care Consent Act (HCCA), Fixing Long Term Care Act (FLTCA)
• Must have First Aid, CPR and WHMIS
• Computer skills in Microsoft Office, MS Word and Excel. Experience with EMR systems, such as PS Suites and Clinical Connect, would be considered an asset.
• Must be familiar with relevant local and area services, hospital or community-based case management and health resources.
• Must be familiar with government funding and legislation related to public services

SUBMISSION PROCEDURE: (Choose one method ONLY):

Method #1:  Online

1. Please visit: My Job Search to access our job board and follow the directions to apply.
2. Please ensure all required documents are provided/uploaded with your application package, which include:
   1. Cover letter including your band name and number (if applicable). Please indicate in your letter how your education and experience qualifies you for this position.
   2. Recent resume clearly identifying that you meet the Basic Qualifications of this position as stipulated above.
   3. Copy of your education diploma/degree/certificate and transcript.
3. If you have any questions or need assistance please reach out to Eniola Owoso, HR Business Partner at 519-445-2223 ext. 5716 or via email at HRBP3@sixnations.ca.

Method #2: GREAT – Applications must include all of the following:

1. Printed, filled in and authorized Six Nations of the Grand River Application for Employment Form.
2. Cover letter including your band name and number (if applicable). Please indicate in your letter how your education and experience qualifies you for this position.
3. Recent resume clearly identifying that you meet the Basic Qualifications of this position as stipulated above.
4. Photocopy of your education diploma/degree/certificate and transcript.
5. Place all documents listed above in a sealed envelope and mail to or drop off at:

Indigenous Transitions Facilitator – Full-Time – 140-25-3

                                         c/o Reception Desk

                                         Grand River Employment & Training (GREAT)

                                         P.O. Box 69, 16 Sunrise Court

                                         Ohsweken, Ontario N0A 1M0

POSITION TITLE:                      Indigenous Transitions Facilitator

REPORTING RELATIONSHIP:

Reports to and works under the direction and supervision of the Home and Community Care Manager, the Senior Manager of Primary and Clinical Care and the Director of Wellbeing.

PURPOSE & SCOPE OF THE POSITION:

To assist the Wellbeing Department in researching, developing, educating and developing strategies for improved discharges for Indigenous people from hospital to home.  The Indigenous Transitions Facilitator is the first point of contact for community members being discharged to services on Six Nations.

The Indigenous Transitions Facilitator will have a caseload of clients currently in the hospital system awaiting discharge, assisting them with system navigation and coordinating proactive continuity of care, collaborating on referrals within the circle of care partners, assisting them with seamless care transitions and provider intersection.  This role will strengthen linkages in the delivery of comprehensive individualized wrap around services and ensure the early engagement of client identified caregivers in the development of their care plan.  They will also determine any education or training required to support the client in their living arrangement of choice upon discharge from a regional facility.  Upon discharge, the Indigenous Transitions Facilitator will transfer the client over to the appropriate Home and Community Care Case Manager.

KEY DUTIES & RESPONSIBILITIES:

Technical Functions
Assessment of current discharge protocols, staff and programs involved in discharge planning, including:

• Building relationships with and meeting regularly with administration, medical and nursing staff, hospitals, discharge planners, social workers, patient navigators and Ontario Health at Home, as well as other related departments
• Assess outcomes of the current discharge plan
• Determine gaps in service and strategize improvement to discharge planning
• Developing and implementing client service plans for the delivery of high-quality service and discharge planning
• Determine the appropriate case manager for handover upon discharge

Administrative Functions

• Follow established reporting procedures as laid out by Six Nations Department of Wellbeing
• Report on progress, failed discharges and outcomes of services by hospital and community as it relates to discharge
• Ensure that the institutions are aware of the resources at SNGR and in other Indigenous communities and agencies and how to access them.
• Provides information and coordinates regular meetings for discharge planning
• Assist staff, clients and families when necessary to promote case conferencing
• Develop and implement policies and procedures for discharge planning
• Regular review of client care and discharge outcomes will be completed to ensure that the right care is delivered to the right client at the right
• Consider client safety and liability issues

Communications Functions

• Working with the existing staff, administration, medical and nursing staff, hospitals, discharge planners, social workers, patient navigators, and Ontario Health at Home discharge planners to develop protocols, resources, and increased collaboration between agencies
• Ensuring Care Plans and Service Plans are appropriate and resources are available to clients and staff
• Assisting clients in providing information, awareness, and direction to create self-determination, responsibility, independence, and autonomy in relation to their own care
• Attend regular meetings to allow open communication and dissemination of information
• Ensuring a successful handover to the Home and Community Care or Palliative Care Case Manager

Other Functions

• Perform other job-related duties as may reasonably be required by the Manager of the Home and Community Care Program
• Provides support for the Six Nations Emergency Measures Plan by ensuring awareness of the Emergency Measures Pan and assistance as instructed by the Director of Wellbeing

WORKING CONDITIONS:

• External contact with referring agencies will require extensive interaction with the public and is subject to deadlines, interruptions, mental stress and unscheduled hours of work.
• Direct client contact, in the hospital and the presence of the client in the office
• Travel in and outside the community as required using own transportation.

WORKING RELATIONSHIPS:

• With the Manager of Home and Community Care and the Senior Manager, Primary and Clinical Care
• Receive direction, guidance, discuss plans, priorities, or interact to ensure tasks are done efficiently and effectively; receives instruction; supervision.

Other staff:

• Works closely with the Home and Community Care Staff, including Case Managers
• Promotes courtesy, cooperation, and teamwork with all staff

With the Public:

• Represents and promotes the Department of Wellbeing with respect to the general awareness of legislation, policy and program changes; seeks to develop sound professional working relationships;
• Provides Public Awareness

KNOWLEDGE AND SKILLS:

Minimum Requirements:

• Bachelor’s or Master’s degree in Nursing, Occupational Health or Social Work
• Minimum of 2 years’ experience working in a hospital setting that includes case management, system navigation, community resources
• Knowledge of relevant legislation, including the Excellent Care for All Act (ECFAA), Freedom of Information and Privacy Protection Act (FIPPA), Personal Health Information Act (PHIPA), Health Care Consent Act (HCCA), Fixing Long Term Care Act (FLTCA)
• Must have First Aid, CPR and WHMIS
• Computer skills in Microsoft Office, MS Word and Excel. Experience with EMR systems, such as PS Suites and Clinical Connect, would be considered an asset.
• Must be familiar with relevant local and area services, hospital or community-based case management and health resources.
• Must be familiar with government funding and legislation related to public services

Other Related Skills:

• Good communication and public relations skills both verbal and written
• Works well as part of a multi-disciplinary team setting
• Demonstrates the ability to understand the importance of confidentiality and ability to work with tact and discretion
• Demonstrated problem solving and critical thinking skills
• Can function independently as well as part of a team
• Must have a clean criminal record check and vulnerable sector screening
• Knowledge about local culture and traditions is preferred
• Must have an insured vehicle and a Class “G” driver’s license.
• Knowledge of or ability to speak an Indigenous language is an asset.

 IMPACT OF ERROR:

Errors in judgment and in the conduct of duties could lead to loss of credibility, poor public relations, confusion, duplication of effort and misinformation being given to the Manager of Home and Community Care, Senior Manager of Primary and Clinical Care and/or Director of Wellbeing, Human Services Committee, Six Nations Elected Council, Government agencies and the general public

CONTROL:

Guiding principles set by the Department of Wellbeing and the Six Nations Elected Council

Must work within the Policies and Procedures established by the Six Nations Elected Council for the Department of Wellbeing