Open Affiliation

Hsnsudbury; Greater Sudbury; On-site; CAD 51,000 - 88,000; Full time

Job summary

Health Sciences North seeks an experienced clinican to oversee transitional care coordination for COPD patients, guiding navigation and care plans across hospital and community settings.

You will work with an integrated care team to ensure timely rehab access, educate patients, and reinforce post-discharge plans, with strong emphasis on evidence-based chronic disease management.

Qualifications

• Current Certificate of Registration in good standing with the applicable regulatory college as a Registered Nurse (RN), Occupational Therapist (OT), Physiotherapist (PT), Masters of Social Work (MSW), Respiratory Therapist (RT), Kinesiologist (Kin), Dietitian (RD), Speech Language Pathologist (SLP), Psychological Associate or Chiropodist.
• Current certificate as a Certified Respiratory Educator (COPD/Asthma Educator) preferred.
• Current certification in Basic Cardiac Life Support (BCLS) / AED required.
• Ministry of Labour “Worker Health and Safety Awareness in 4 Steps” training certificate required.

Responsibilities

• Coordinate seamless transitions of care for COPD patients discharged from acute care settings.
• Collaborate with primary care providers, specialists, home care agencies, and community programs for coordinated care.
• Ensure timely connection to Pulmonary Rehabilitation and outpatient follow-up services.
• Assess condition changes and relay information to physicians and team members.
• Review discharge plans and identify gaps or barriers to successful community transition.
• Serve as a central resource hub for COPD patients and caregivers.
• Assist patients in navigating healthcare services and community resources.
• Provide education on COPD management, inhaler techniques, oxygen therapy, and lifestyle modifications.
• Reinforce discharge instructions and treatment plans to improve understanding and adherence.
• Support patients in developing self-management skills and confidence at home.
• Promote participation in Pulmonary Rehabilitation and chronic disease management programs.
• Conduct follow-up calls post-discharge to assess status and concerns.

Skills

COPD care knowledge

Care transitions

Patient education

Communication

Care coordination

Problem-solving

MS Office

Team collaboration

Education

RN/OT/PT/MSW/RT/Kin/RD/SLP/PA/Chiropodist registration

Certified Respiratory Educator (preferred)

BCLS/AED certification

OSH/Workplace safety training

Tools

Microsoft Office

Job description

Select how often (in days) to receive an alert: Create Alert

Cardiac & Pulmonary Rehabilitation ONA Paramedical

Salary Information

$36.84 - $63.62 / hour (rate to be determined based on applicable Collective Agreement)

Application Closing Date

October 28, 2026

KEY FUNCTION:

Oversee transitional care coordination and patient navigation to support community transitions for patients living with Chronic Obstructive Pulmonary Disease (COPD).

REPORTING:

Under the general direction of the Clinical Manager, Integrated Chronic Pain Program, OBIRS, CDSMP, HAVEN/Hemophilia/Hemoglobinopathy, Cardiac and Pulmonary Rehabilitation and Outpatient Neurological Rehabilitation.

DUTIES:

• Coordinate seamless transitions of care for COPD patients discharged from acute care settings.
• Collaborate with primary care providers, specialists, home care agencies, and community programs to support coordinated care delivery; ensure patient goals and preferences are documented and communicated appropriately.
• Ensure timely connection to Pulmonary Rehabilitation and outpatient follow-up services.
• Assess condition changes and medication effects and relay relevant information to physicians and team members.
• Review discharge plans and identify potential gaps or barriers to successful community transition.
• Serve as a central resource hub for COPD patients and caregivers.
• Assist patients in navigating healthcare services and community resources.
• Connect individuals to appropriate support services, including home care, smoking cessation programs, respiratory equipment providers, transportation services, financial assistance programs, and social supports.
• Provide individualized education on COPD disease management, symptom recognition, inhaler techniques, oxygen therapy, and lifestyle modifications.
• Reinforce discharge instructions and treatment plans to improve understanding and adherence.
• Support patients in developing self-management skills and confidence in managing their condition at home.
• Promote participation in Pulmonary Rehabilitation and evidence-based chronic disease management programs at local and regional level.
• Conduct scheduled follow-up calls following hospital discharge to assess patient status, identify concerns, and reinforce care plans.
• Monitor symptoms, treatment adherence, and functional status during the post-discharge period.
• Identify early warning signs of exacerbation and facilitate timely intervention.
• Ensure follow-up appointments, diagnostic testing, and specialist consultations are completed as required.
• Utilize established clinical pathways and escalation protocols to facilitate timely intervention by appropriate healthcare providers.
• Communicate urgent concerns to physicians, respiratory therapists, nursing teams, or other members of the care team as required.
• Initiate and support early conversations regarding goals of care, advance care planning, and future healthcare preferences.
• Provide education regarding advance directives and available supportive care resources.
• Work closely with inpatient Medicine, Respiratory Therapy, Pulmonology, nursing, and allied health teams to support coordinated patient care.
• Participate in multidisciplinary rounds, case conferences, and care planning meetings as required.
• Maintain accurate documentation and care coordination records in the electronic medical record.
• Track program metrics such as readmission rates, emergency department utilization, follow-up completion, and patient engagement.
• Contribute to quality improvement initiatives focused on care transitions, patient outcomes, and service effectiveness.
• Evaluate patient care and satisfaction on an ongoing basis and formulate solutions for improvement.
• Determine and align improvement projects with HSN’s Strategic Plan; monitor and adjust to achieve goal outcomes.
• Contribute to learner development by providing academic support, mentorship, preceptorship and supervision as required.
• Participate in education and training specific to current, relevant federal and provincial health and safety legislation, standards and guidelines.
• Educate and promote health, safety and wellness in the work place.
• Represent the department or program on various committees and in meetings as required.
• Perform other duties as required.

QUALIFICATIONS

EDUCATION AND TRAINING:

• Current Certificate of Registration in good standing with the applicable regulatory college, as a Registered Nurse (RN), Occupational Therapist (OT), Physiotherapist (PT), Masters of Social Work (MSW), Respiratory Therapist (RT), Kinesiologist (Kin), Dietitian (RD), Speech Language Pathologist (SLP), Psychological Associate or Chiropodist.
• Current certificate as a Certified Respiratory Educator (i.e. Chronic Obstructive Pulmonary Disease (COPD) and / or Asthma Educator) is preferred.
• Current certification in Basic Cardiac Life Support (BCLS) / Automated External Defibrillator(AED) is required.
• Ministry of Labour “Worker Health and Safety Awareness in 4 Steps” training certificate is required.

EXPERIENCE:

• Minimum of two (2) years’ full-time equivalent experience (within the last 5 years) providing adult education.
• Minimum of one (1) year full-time equivalent experience working within a multi-disciplinary team.
• Two (2) years’ full time equivalent experience providing pulmonary rehabilitation care is preferred.
• Two (2) years’ experience working in case management is preferred.

KNOWLEDGE/SKILLS/ABILITIES:

• Demonstrated strong understanding of COPD management, pulmonary rehabilitation principles, and evidence-based chronic disease care.
• Demonstrated knowledge of care transition best practices and patient-centered care approaches.
• Demonstrated coaching and patient education skills.
• Demonstrated planning, analytical, and problem-solving skills.
• Demonstrated excellent presentation skills.
• Demonstrated training, experience or utilization of quality improvement methodology for process improvement.
• Demonstrated ability to independently identify issues, plan improvements, measure success and continue improvement.
• Demonstrated excellent computer skills with proficiency in Microsoft Office software (e.g. Word, Excel, Power Point and Outlook) and patient information systems.
• Demonstrated superior interpersonal and communication skills, both written and verbal.
• Demonstrated ability to manage routine correspondence, multiple tasks/projects, diversified workload and rapidly changing priorities and challenging deadlines.
• Demonstrated discretion and maturity when handling confidential information.
• Demonstrated commitment to the safety of co-workers and patients.
• Successful Vulnerable Sector Check is required.
• Ability to use tact and discretion in dealing with health care providers and patients.
• Proven ability to work independently and in a team environment.
• Valid driver’s license with access to reliable vehicle.
• Willingness to travel occasionally within Ontario.
• Demonstrated commitment to ongoing professional development.
• Demonstrated professionalism in dealing with confidential and sensitive issues.
• Demonstrated positive work record and excellent attendance record.
• Ability to meet the physical and sensory demands of the job.
• Ability to travel between local sites.

Selection Process: Candidates will be selected for this position on the basis of their skill, ability, experience and qualifications as identified in the resume and completed Application Form submitted. The Hospital reserves the right to conduct a formal interview where required. This posting is for an existing vacancy.

Health Sciences North is committed to providing accommodations to applicants with disabilities to enable their participation in the recruitment, assessment, selection and hiring stages of employment.

HSN THANKS ALL APPLICANTS. ONLY THOSE SELECTED FOR INTERVIEWS WILL BE CONTACTED. WE WILL NOT ACCEPT APPLICATIONS AFTER THE CLOSING DATE AND TIME.