Position: Palliative Nurse Navigator (1.0 FTE)
Reports To: Manager Specialized Programs

Position Summary
As a key member of the Couchiching Family Health Team (CFHT), and an integral part of an
interdisciplinary health care team, you will deliver nursing care in accordance with FHT policies
and professional practice standards. The Palliative Nurse Navigator is a specialist in palliative
care and is responsible for the planning, coordination and delivery of palliative and end of life
care to patients and their families and caregivers. Working in collaboration with an
interdisciplinary team, the Palliative Nurse Navigator will provide clinical and educational
support and facilitate care connections across the health care sectors for clients requiring
palliative care in the community. As well, you will provide expert clinical palliative leadership
to support seamless, integrated care delivery. The Palliative Nurse Navigator will apply an
anti-oppressive lens in supporting diverse patients, including those facing systemic barriers.

Why Join Us:
Join a collaborative, team-based primary care environment focused on improving access and
continuity of care in the community, and be part of a progressive organization advancing Ontario
Health’s Primary Care for All initiative.

Roles and Responsibilities

• Screen, prioritize and process client referrals
• Consult with Primary Care Practitioners and specialists and review client clinical information
  obtained through the Primary Care Practitioner and client health records
• Provide client-centred case management, including assessment, service coordination, and
  evaluation, and
  a direct report to the Primary Care Practitioner, specialist involved in client’s care
• Link with community resources, particularly supportive care and palliative care facilities and
  services and share information to provide the best experience for the client
• In collaboration with the Primary Care Practitioner and other members of the interdisciplinary
  team, develop and discuss an appropriate individualized care plan with the client/family/caregiver
  based on best practice
• Recommend and teach client’s treatment protocols and education as required
• Liaise with other palliative care providers within the circle of care at palliative care rounds
  and provide home visits as required for integrated care delivery, adhering to the CFHT Home Visit
  Policy Guidelines
• Palliative pain assessment and management to assist Most Responsible Primary Care Practitioner
  (MRPCPs) with treating pain effectively in the palliative and end of life setting in the home.
  Suggest and support the MRPCP with appropriate directions in order to properly treat pain
• Indication to MRPCP what the patient’s current Palliative Performance Scale (PPS) is to alert
  the MRPCP
  to any changes that may need to be addressed to help improve Quality of Life (QOL)
• Implementing Edmonton Symptom Assessment Scale (ESAS) with every patient encounter to provide
  the MRPCP with an indication of what symptoms are paramount for the patient at any given time and
  assist the MRPCP with the appropriate treatment and avoid hospitalization
• Actively participate in staff, team and committee meetings, if appropriate
• Participate in the development, planning and evaluation of treatment, education, counselling and
  health promotion activities of the FHT
• Of note: The CFHT palliative care coordinator does not routinely administer symptomatic
  medications; however, in circumstances where a patient is experiencing significant symptoms that
  may be managed using medications contained within the Pain and Symptom Relief Kit available in the
  home, the CFHT palliative care nurse may, based on clinical knowledge, skill, and judgement and
  within scope of practice, administer these medications in accordance with orders provided by the
  most responsible primary care provider (MRPCP). All interventions must be documented in the medical
  record accordingly.
• Work in compliance with Health and Safety laws adhering to safe work practices and procedures
  established by the CFHT
• Other duties as required

Organizational Nursing Support

• Adapt to the staffing needs of the CFHT by assisting with Nursing responsibilities in other CFHT
  programs and services as required

Reporting

• Prepare quarterly reports and monitor daily statistical data to ensure statistics are reported
  to the Ministry of Health in a timely fashion
• Accurate and timely documentation into the Electronic Medical Record as per the CFHT
  Documentation Policy. Given the changing nature of health status within the Palliative Patient,
  however, priority must be given to recording details of sessions and documentation must be
  completed within 24 hours of the appointment.

Professional Development

• Maintain and develop professional competence through ongoing professional development
• Stay current and aware of opportunities to implement new, evidence-based methods of client
  assessment, treatment and programming
• Maintain and upgrade knowledge and skills
• Participate in clinical projects as required

Education/Specific Job Requirements:

• Baccalaureate degree in Nursing (or equivalent), Masters preferred
• Current Basic Cardiac Life Support
• Current membership and in good standing with the College of Nurses of Ontario (CNO)
• Current membership in Registered Nurses Association of Ontario (RNAO) preferred
• Demonstrated understanding of client-centred case management, including assessment, service
  coordination, and evaluation
• Demonstrated and comprehensive understanding of ethical decision-making principles, palliative
  care philosophy, and quality end of life care planning
• Demonstrated working knowledge of community resources, particularly supportive care and
  palliative care facilities and services
• Demonstrated evidence of sound organizational, prioritization, and conflict management skills
  with the ability to work well in stressful situations
• Excellent communication, negotiation, teaching and interpersonal skills with the ability to work
  well with patients, families, all levels of staff and the community
• Demonstrated ability to work well autonomously
• Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection
  of Privacy Act
• Flexible to meet additional responsibilities as program demands
• Positive attendance and work record essential
• Able to work flexible hours including evenings if required
• Police Record/Vulnerable Sector Check
• It is a condition of employment that you receive the necessary vaccinations to protect against
  infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental
  and public health authorities from time to time

Experience:

• Demonstrated clinical competence in nursing practice with 3-5 years recent experience working in
  a palliative care/oncology/hospice environment. Preference will be given to those candidates with
  foundations in oncology courses and CNA Palliative/Hospice Care certification
• Highly experienced with physical assessment as well as competence in emotional assessment to
  assist MRPCP with developing an appropriate plan of care as per patient wishes
• Relevant community-based or lived experience working with palliative clients, their families,
  and/or caregivers may be considered an asset

The Couchiching Family Health Team supports diversity, equity and a workplace free from harassment
and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection
process and workplace. If you are contacted to participate in our recruitment process, please
advise the interview coordinator of any accommodations. The CFHT has an Accommodation Policy and
Procedure to ensure you have access to a fair and equitable process. While we thank all applicants,
only those contacted for an interview will be acknowledged.

Please submit cover letter and resume including position title in subject line to: careers@cfht.ca.
Only those selected for an interview will be contacted.