Indig. Transitions Facilitator

Royal Victoria Regional Health Centre; Canada; On-site; CAD 72,000 - 83,000; Full time

Job summary

Royal Victoria Regional Health Centre is seeking an Indigenous Transitions Facilitator to support timely and safe discharges of Indigenous patients from hospital to home or community settings. The role integrates clinical resource management with patient navigation to ensure goals of care are met in a culturally safe manner.

The ITF works within an interdisciplinary team, coordinating discharge planning, education, and navigation to connect patients with home care services and community

Qualifications

• Registered Health Professional with current and unencumbered registration with the College of Nurses of Ontario (CNO) or relevant regulatory body
• Baccalaureate degree in Nursing or a health-related discipline required
• Current Basic Life Support (BLS) certification required

Responsibilities

• Develop and facilitate individualized care planning and discharge processes to optimize patient flow across the organization
• Serve as the primary point of contact for Indigenous patients and families during hospital discharge planning
• Provide education, navigation, and support to patients and families around home care services, financial resources, and available community supports
• Medication reconciliation and health teaching
• Assess patient eligibility for homecare and community programs based on established criteria
• Collaborate with interdisciplinary teams to determine estimated discharge dates and coordinate community supports
• Liaise with external providers and system partners to develop and implement comprehensive plans of care that meet post-acute needs
• Contribute to the improvement of discharge processes, flow strategies, and resource utilization throughout the organization

Skills

Interprofessional collaboration

Communication

Cultural safety

Discharge planning

Education

RN with CNO

Baccalaureate degree in Nursing

BLS certification

Tools

Meditech

Microsoft Office

Outlook

Job description

Indig. Transitions Facilitator - (24349)

Job Title

Indig. Transitions Facilitator

Program & Department

Regular / Temporary

Regular

Full / Part Time

Full-Time

Temporary End Date (Anticipated)

Union

Non Union

Requisition Close Date

16 October 2026

Salary Plan / Job Grade

$51.76 - $60.89 ( NU_08 )

Job Posting Reason

Current Vacancy

Job Summary & Requirements

The Indigenous Transitions Facilitator role aligns with strategic direction from Indigenous Services Canada, and with the foundational strategic priorities identified in the Letters of Relationship between RVH and Barrie and Area Native Advisory Circle – Indigenous Health Circle (BANAC - IHC).

The Indigenous Transitions Facilitator (ITF) is a key member of the interdisciplinary team responsible for supporting timely and safe discharges of Indigenous patients from hospital to home or the most appropriate community setting. This role combines effective clinical resource management with patient navigation, ensuring that goals of care are met while facilitating equitable access and culturally safe care.

Responsibilities:

• Develop and facilitate individualized care planning and discharge processes to optimize patient flow across the organization
• Serve as the primary point of contact for Indigenous patients and families during hospital discharge planning
• Provide education, navigation, and support to patients and families around home care services, financial resources, and available community supports
• Medication reconciliation and health teaching
• Assess patient eligibility for homecare and community programs based on established criteria
• Collaborate with interdisciplinary teams to determine estimated discharge dates and coordinate community supports
• Liaise with external providers and system partners, including Home and Community Care services such Ontario Health atHome and First Nation Homecare Programs, Jordan’s Principle and Non-Insured Health Benefits (NIHB) to develop and implement comprehensive plans of care that meet post-acute needs
• Contribute to the improvement of discharge processes, flow strategies, and resource utilization throughout the organization

Qualifications:

Education:

• Registered Health Professional with current and unencumbered registration with the College of Nurses of Ontario (CNO) or relevant regulatory body
• Baccalaureate degree in Nursing or a health-related discipline required
• Current Basic Life Support (BLS) certification required

Experience:

• Minimum 5 years of clinical experience in diverse settings (e.g., medical/surgical, emergency, and/or community) preferred
• Demonstrated experience in discharge planning, case management, and utilization management aligning with Health Quality Ontario’s Transitions Between Hospital and Home, Care for People of All Ages Quality Standard
• Strong knowledge of community-based resources, supports, and systems
• Experience working with vulnerable and medically complex patient populations
• Lived experience within an Indigenous community, combined with knowledge of Indigenous cultural practices
• Experience and understanding of First Nation, Métis and Inuit history, culture, health determinants, and perspectives on health and well-being
• Strong interpersonal, communication, and collaboration skills with the ability to foster trust with patients, families, and interprofessional teams
• Commitment to providing culturally safe, trauma-informed, patient- and family-centered care
• Proven organizational and problem-solving skills with the ability to prioritize and multi-task in a fast-paced environment
• Effective critical thinking and clinical judgment in decision-making and resource coordination
• Ability to adapt to change and take initiative on projects with minimal supervision

Other:

• Proficiency in Microsoft Office and Outlook; working knowledge of Meditech and financial/healthcare reporting systems an asset
• Demonstrated alignment with RVH values: Team up, Be kind, Do great things, Inspire trust, Be bold
• Upholds professional standards, patient safety, and contributes to a healthy work environment in accordance with health and safety legislation

Exhibits the core values of Royal Victoria Regional Health Centre: Inspire Trust, Be Kind, Be Bold, Do Great Things, Team Up.

Equity & Inclusion

RVH is committed to recruitment and selection practices anchored in principles of equity and inclusion that contribute to an anti-oppressive, respectful, and culturally safe workplace.

We invite applications from individuals who belong to groups that have been historically marginalized on the grounds identified by the Ontario Human Right Code, including but not limited to race, disability, age, gender expression, gender identity, sexual orientation, religion, family or marital status, and status as a First Nation, Métis, or Inuk person.

Accommodations

RVH is dedicated to ensuring every applicant has a fair and equitable opportunity to demonstrate their knowledge, skills, and abilities throughout our recruitment and selection process. We are continuously working to create an accessible, barrier-free process, and recognize each applicant’s needs are different.

We encourage applicants with a disability or circumstance that could be supported with an accommodation to contact People Recruitment at [e-mail].

RVH does not use artificial intelligence (AI) to screen, assess, or select applicants.

Equity & Inclusion

RVH is committed to recruitment and selection practices anchored in principles of equity and inclusion that contribute to an anti-oppressive, respectful, and culturally safe workplace.

We invite applications from individuals who belong to groups that have been historically marginalized on the grounds identified by the Ontario Human Right Code, including but not limited to race, disability, age, gender expression, gender identity, sexual orientation, religion, family or marital status, and status as a First Nation, Métis, or Inuk person.

Accommodations

RVH is dedicated to ensuring every applicant has a fair and equitable opportunity to demonstrate their knowledge, skills, and abilities throughout our recruitment and selection process. We are continuously working to create an accessible, barrier-free process, and recognize each applicant’s needs are different.

We encourage applicants with a disability or circumstance that could be supported with an accommodation to contact People Recruitment at [e-mail].

RVH does not use artificial intelligence (AI) to screen, assess, or select applicants.

To learn about how RVH is taking steps to create and sustain an equitable, inclusive, accessible and culturally-safe environment, please visit: https://www.rvh.on.ca/about-rvh/equity-inclusion/