Indigenous Care Coordinator

Full Time
Thunder Bay
Posted 5 months ago

Grand Council Treaty #3 in partnership with Thunder Bay Regional Health Sciences Centre


Are you passionate about improving the health and mental health outcomes of Indigenous peoples by providing culturally appropriate and safe care? Do you have experience with health system navigation and discharge planning? Grand Council Treaty #3 is currently hiring an Indigenous Care Coordinator in partnership with Thunder Bay Regional Health Sciences Centre (TBRHSC), as part of a new collaborative pilot program between Grand Council Treaty #3, Anishinabek Nation-Union of Ontario Indians (Anishinabek Nation), Anishnawbe Mushkiki and the TBRHSC.

The Indigenous Care Coordinator (ICC) is based in TBRHSC and reports to the Provincial Policy Analyst, Grand Council Treaty #3.  The ICC will work as part of an interprofessional team, including other ICCs who report to Anishnawbe Mushkiki and Anishinabek Nation. The ICC will be part of TBRHSC Circle of Care Team under the supervision of the TBRHSC’s Senior Director of Indigenous Collaboration.

The ICC is responsible for providing a range of health and mental health navigation, advocacy, discharge planning and supports services to Indigenous peoples accessing health and mental health services at TBRHSC.

The goal of the program is to improve equitable access to care for Indigenous patients and support their return home through rigorous discharge planning processes and supports that leverage community/region-based services that are culturally appropriate and safe. The ICC will work with local communities to support the smooth transition of patients back to their homes as appropriate.

The ICC will primarily be responsible and accountable for care coordination in the Grand Council Treaty #3 territory area; however, the position will work with other ICCs to support continuous coverage and manageable workloads. Each ICC will be a specialist of their area as well as generalists of services available for Indigenous people throughout northwestern Ontario.

Grand Council Treaty #3 and the TBRHSC are committed to delivering healthcare in a manner that is consistent with Patient and Family Centered Care.  Applicants are required to have a demonstrated knowledge, understanding and commitment to this care philosophy.


Reporting to Grand Council Treaty #3’s Provincial Policy Analyst, and under the supervision of the TBRHSC’s Senior Director of Indigenous Collaboration and in accordance with Hospital policies, standards and procedures, the ICC is responsible for:

Planning/Coordinating & Supports:

  • Facilitate a patient-centered discharge plan with the physician / health care practitioner (responsible for recommending discharge and any follow-up requirements), patient, family/significant others, and interprofessional team.
  • Receive and process referrals and inquiries and provide clear and accurate information on available community-based services to support patients in accessing and optimizing the available services and supports.
  • Participate in bed rounds to support patients, nursing staff and interprofessional team to develop appropriate plan of care and discharge plan.
  • Coordinate case conferences and trial discharges for complex patient discharges.
  • Support individuals and families to make necessary arrangements for assisted living, respite, and/or placement of names on waiting lists for facility care.
  • Liaise with service providers and suppliers to arrange and authorize necessary services, equipment and devices, medical supplies, and transportation.
  • Facilitate referrals to home and community care for alternative level of care and supportive resources (e.g. holistic healing and wellness services, mental health and addictions programs, St. Joseph’s Care Group programs and other community-based organizations, programs and services).
  • Provide advocacy supports for patients and their families/support systems as required to support equitable access to quality care.
  • Coordinate with psychiatrists and mental health physicians / specialists to support the needs of Indigenous patients with mental health and addictions issues, including developing an appropriate plan of care and discharge and aftercare plan.

Organizational Responsibilities:

  • Attend quarterly meetings with Grand Council Treaty #3 management to report back on program outcomes.
  • Participate in Grand Council Treaty #3 and TBRHSC-led trainings, as relevant / appropriate.
  • Propose changes within the Hospital that would improve the quality of service to Indigenous patients and their families.
  • Apply Indigenous culture, values, traditions and teachings into programming / operations where possible.
  • Assist and support the development of specific policies or protocols for Grand Council Treaty #3 and TBRHSC to improve access and provision of culturally appropriate and safe services for Indigenous peoples.


  • Foster intra/interprofessional collaborative relationships through respectful communication and knowledge of all team members’ roles and responsibilities.
  • Facilitate conflict resolution and critical thinking among team members.
  • Advise/assist the patient interprofessional team in specific project activities related to patient flow and implementation of evidence-based/best practices.


  • Practice excellent interpersonal communication techniques with internal and external partners/stakeholders to achieve efficient patient flow and effective transitions in care.
  • Document discharge plan as part of comprehensive plan of care.
  • Participate in community outreach activities to promote the program.
  • Communicate effectively with patients, families, and/or communities throughout patient journey of care.
  • Develop and maintain collaborative working relationships with other Indigenous Care Coordinators, leaders and health care groups within the community and region to ensure consistency of planning to meet patient needs.
  • If able, provide Indigenous language interpretation services as needed to support the accurate transmission of health care information to patients and their families/ support systems. (If unable, work with TBRHSC’s Indigenous interpreters.)


  • Provide or connect individuals and their families with educational materials and resources (e.g. understanding their health needs and treatments, community resources, understanding provincial and federal health systems).
  • Serve as an operational resource to interprofessional team in the management of discharges by educating the interprofessional team regarding the discharge planning process and availability of community / regional services and supports.

Quality & Risk Management:

  • Provide insights to interprofessional team and hospital staff on providing culturally safe and appropriate care.
  • Assist in evaluation of patient care outcomes through various audits, chart reviews or other data collection methods.
  • Assist with quality/process improvement initiatives and evaluation of ICC program.
  • Assist with timely response of safety reports and patient compliments and concerns.
  • Identify and report risk management issues related to practice, process or patient care delivery.


Essential Requirements:

  • Registered Practical Nurse (RPN) Diploma* or Registered Nurse (RN) Baccalaureate* (unencumbered registration with the College of Nurses of Ontario (CNO)*), or Masters of Social Work (unencumbered registration with the Ontario College of Social Workers and Social Service Workers (OCSWSSW))
  • Knowledge and understanding of CNO Standards of Practice, or OCSWSSW Standards of Practice, as applicable
  • Experience working with Indigenous peoples and communities and providing culturally safe and patient-centered care
  • Proven ability to build relationships and work as a member of an interprofessional team
  • Excellent interpersonal and communication skills including the ability to provide constructive feedback and resolve conflict
  • Excellent documentation/written skills
  • Working knowledge of the provincial and federal health care systems as it pertains to Indigenous people
  • Demonstrated ability to work under pressure and manage competing work demands
  • Knowledge of and experience with case management

*Consideration will be made for new nursing graduates awaiting registration exam


  • Fluent in Ojibway and/or Oji Cree
  • Demonstrated discharge planning experience
  • Knowledge of the local and regional mental health and addictions resources and availability, community services and supports
  • Demonstrated sound clinical knowledge and experience in home care and/or community-based service delivery
  • Experience as a liaison between the Hospital and local community organizations in order to meet the needs of Indigenous patients/clients
  • Knowledge of team-building principles and interprofessional collaboration


  • Must be willing and able to work flexible hours and provide on-call services as required
  • Must be certified in CPR and Standard First Aid
  • Valid driver’s license, in good standing and a reliable vehicle
  • Criminal records/vulnerable sector check and child welfare check is required upon hiring
  • Work site location is Thunder Bay Regional Health Sciences Centre
  • Travel may be required within Thunder Bay and surrounding areas

Grand Council Treaty #3 and the TBRHSC strive to ensure the safety and security of the patients, visitors, employees and assets of the organizations, financial and otherwise.  As one tool in the recruitment screening process, all offers of employment to external candidates shall be conditional upon a satisfactory Vulnerable Sector Check (VSC) to ensure the absence of relevant criminal convictions.

Applicants must clearly demonstrate in their covering letter how they meet the qualification requirement of this position. Submit cover letter, resume, and contact information for 3 references to the attention of:

Human Resources Manager
Grand Council Treaty #3
P.O Box 1720 Kenora, Ontario P9N 3X7
Fax:  807-548-6356

We are committed to fostering an inclusive, equitable, and accessible environment supporting diversity in our work environment to provide quality care where all feel valued, respected, and supported. We are dedicated to building a workforce reflective of the communities in which we live and serve and encourage Indigenous people, visible minorities, and persons with disabilities to apply and self‑identify. Upon request, accommodations due to a disability are available throughout the selection process

PDF – Indigenous Care Coordinator Job Posting

Job Features

Job CategoryHealth
LocationThunder Bay Regional Health Sciences Centre
Closing DateOpen until filled

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