Patient Care Navigator - Halton Healthcare, Oakville

Position summary

Be a key part of the Community Integration and Primary Health Care Program by helping patients with complex health and social needs transition seamlessly from hospital to home. As a Halton@Home Patient Care Navigator, you will collaborate with an interdisciplinary team, provide compassionate care, and ensure that patients receive the right support at the right time. Your work will directly impact patient outcomes, reduce hospital readmissions, and contribute to a strong, community-focused health care system.

Responsibilities

• Coordinate Transitions to Home: Identify and assess patients eligible for the Halton@Home Program, ensuring timely discharge and smooth transitions from hospital to community care.
• Create Patient-Centered Care Plans: Develop, implement, and monitor personalized care plans in collaboration with patients, families, and our dedicated health care team. Recommend and facilitate the multi-disciplinary supports needed to meet the patient's needs in the community.
• Advocate for Patients: Act as a liaison between patients, families, and community service providers, ensuring they have the resources and support needed for a successful recovery at home. Monitor service delivery and follow up after discharge to identify and address opportunities.
• Contribute to Program Growth: Share your insights and ideas to help evolve the Halton@Home Program, improving patient care and community resources through continuous feedback and collaboration.
• Collaborate Across the Community: Build strong relationships with community organizations, primary care providers, and home care services to ensure a coordinated, patient-focused approach to care.

Qualifications

Halton Healthcare endeavors to hire individuals who are competent in their chosen profession and who exemplify our mission, vision and values of accountability, respect and compassion which guide our individual behaviours and attitudes.

• Bachelors degree in a Health Discipline is required
• Masters degree in a Health Discipline is preferred
• Current membership in good standing with a regulatory health professional body in Ontario
• 2 to 5 years of recent work experience in a hospital setting, with liaison experience in community health settings
• 3 years of recent related experience in Emergency Department, acute care, post acute care, discharge planning, and/or community health care settings
• Experience in performing case management or care navigation functions, particularly in acute, post acute, and community settings
• Demonstrated knowledge and expertise related to a variety of health, functional and social challenges, particularly in areas such as geriatrics, chronic disease management, complex family systems, and the care of the frail elderly
• Evidence of program design and resource development skills, including knowledge of evaluation methodologies
• Comprehensive knowledge of community resources and health care delivery systems across acute and community settings
• Demonstrated ability to respond to patients with flexibility, adaptability, and a commitment to patient-centered, holistic care
• Strong understanding of collaborative practices, including building relationships internally and with community partners
• Demonstrated ability to work independently and collaboratively with interdisciplinary teams, family members, support networks, and a variety of formal and informal service providers
• Strong leadership skills, including problem-solving, critical thinking, conflict resolution, and negotiation abilities
• Excellent interpersonal, communication, organizational, and decision-making skills
• Exceptional time management and stress management skills
• Comfortable working in an evolving program with changing responsibilities over time
• Fluency in English, verbal and written
• Proficiency in electronic medical record systems; experience with Meditech and CHRIS is preferred
• Computer literacy and proficiency required, including Microsoft 365 applications such as Outlook, Excel, Word, PowerPoint, SharePoint, and OneDrive
• Positive attendance record