Job Description

:Under Palliative Care Program at Unity Health, the Palliative Care Navigator will work in the hospital and community homeless service settings. The Palliative Care program across Unity Health seeks to provide holistic world class end of life care, grounded in dignity and respect for the individual and those they call family. This role will work directly with the Palliative Care team, with one navigator working primarily at St. Michaels and in the downtown catchment area and the second working at Providence and in the Providence catchment area.The Navigator is responsible for assisting those who are vulnerably housed and/or experiencing health inequities within the context of being diagnosed with a life limiting illness, navigate the health care system. This role works as part of a multidisciplinary team in palliative care, to improve access to health services, improve service coordination and transitions for chronically homeless, vulnerably housed and equity deserving populations with life limiting illness, where they wish to receive their care. The Navigator will support transitions from hospital to the community and the community to hospital as needed, and will support a roster of patients who are community dwelling.Responsibilities:

• Establishes and maintains therapeutic rapport with patients to facilitate treatment plans as part of a multi-disciplinary team;
• Effectively assists patients through their life limiting diagnosis and actively works with patients to build a care plan that meets their needs, in the patients preferred environment;
• Employs evidence-informed health screening and assessment tools to identify health problems that might influence the patients treatment plan;
• Meets new patients to complete a psychosocial assessment and to agree to a plan for support informed by best practice;
• Bridge gaps to accessing palliative care supports;
• Acts as an advocate and educator on end of life care;
• Assists with completion of documents such as: Power of Attorney (POA), advanced directives, wills and funeral arrangements;
• Provides outreach support to patients as needed i.e. to help access financial and housing based resources, connect with agencies and improve community connections/integration;
• Works with the interdisciplinary team to access funding to eliminate barriers to discharge;
• Links patients to supports in the community for those who are: uninsured; experience mental illness; or require addictions support;
• Works collaboratively with the team to ensure quality care to patients;
• Works diligently to foster excellent relationships with internal and external partners;
• Stays current with best practice in palliative care;
• Keeps the care team advised of patient, community and inter-agency relationships and concerns;
• Engages in periodic evaluation and review of treatment goals and re-negotiates goals as is appropriate;
• Participates in patient case management meetings when requested by either the patient or the care team;
• Discusses concerns of patient suitability with the CLM and most responsible provider if necessary;
• Engages in regular case conferenceswith the CLM and most responsible provider and reports unusual occurrences immediately;

• Records all patient interactions in an objective and accurate manner that reflects organizational protocols and established regulatory practices;
• Document all stages of the treatment process clearly, accurately and concisely.
• Builds partnerships with community agencies including developing and implementing referral pathways;

• Acts as a liaison with the community agencies to ensure appropriate patient referrals;

• Engages in day-to-day liaison activities with relevant professionals and community members;
• Promotes and maintains community relationship with key stake holders;
• Strengthen internal partnerships with the SMH mental health and Homeless program;

• Collaborate with in-patient units to facilitate coordinated transitions to and from the community.

• Masters in Social Work or willing to consider Nurse with the right experience and background
• Knowledge of palliative care principles and the philosophy of end of life care provision;
• Knowledge of Homeless treatment modalities;
• Must be willing to travel to off-site agencies;
• Experience in mental health, population health and health services navigation;
• Background in Social Work is an asset.

Unity Health Toronto