Patient Flow Navigator - SCOPE Navigator

Position Summary:

Reporting to the Manager, Community Integration, The SCOPE Navigator leads the system navigation focus on the program and collaborates with the members of the SCOPE Interprofessional team. Integration SCOPE (Seamless Care Optimizing the Patient Experience) is a quality improvement collaboration between hospital and solo primary care providers (PCPs) located in the Western York Region (WYR) area. The SCOPE service is a virtual interprofessional team that facilitates greater access to hospital based interdisciplinary resources and other specialists care. SCOPE aims to help reduce avoidable ED visits and hospital re-admissions for patients in need. The SCOPE Navigator will ensure that the appropriate supports are provided to patients, families, and various service providers through education, assessment, intervention and coordination within the care pathway.

Contribute to safe, quality care by

• Managing a workload effectively in a fast-paced environment.
• Addressing and resolving issues in a productive, respectful manner.
• Exercising sound professional judgment and using best practice guidelines.
• Contributing to a safe, inclusive environment for all through compliance with patient and staff safety policies and procedures.
• Serve as a point of access to connect family physicians to appropriate community, clinical and specialized supports to address patient health concerns

• Respond to all calls and emails made to Scope Navigation Hub by the PCPs and their administrative assistants
• Triage and forward referrals to appropriate SCOPE contact (i.e. Internist, Nurse Navigator or Coordinator)
• Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)
• Understand and clarify PCP primary concerns and request for support
• Collaborate with the health care team to improve patient care as they transition through the health care system
• Review available/relevant information to determine assessment and care planning
• If client is an existing or former clinic patient, will re-connect with staff to communicate PCP concerns and request for assessment
• Enhance workflow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client. This includes the clarification of referral criteria and identification of the resource that will best suit the health care need
• Improve communication and collaboration between consultants and primary care services by assisting PCP staff in the compilation of referral packages and follow-up of referrals
• Provide PCP or PCP staff with clinic/referral information
• Navigate hospital clinics and resources that will assist PCP with managing client medical, functional, cognitive, psychosocial conditions
• Direct requests for consultations or medical workups to SCOPE’s on-call physicians
• Attend Primary Care Project meetings, as required
• Attend SCOPE Implementation Meetings and consult with SCOPE’s medical lead between case round for assessment, support and medical advice
• Develop community linkages and partnerships with various organizations and resources within the
• community
• Elicit feedback on SCOPE and implement process and service improvements, as appropriate
• Collect data for the evaluation of the SCOPE research protocol

What must you have?

• Minimum of 3 years of experience within acute care and/or primary/community care
• Undergraduate degree in a health-related field or equivalent combination of education and experience, required.
• Current registration with an accredited professional College or Association, required.
• Proven clinical experience with patient-focused care, including strong patient assessment, care planning, patient education and documentation skills.
• Recent completion of a physical assessment course or willingness to obtain within 1 year of employment
• Experience working within an Interprofessional team environment as well as independently and autonomously
• Experience working with older patients with complex medical needs required
• Must be flexible and able to adapt to changing environments and travel outside of hospital
• Must possess a valid Ontario Driver’s License and have access to own transportation.

What else do you bring?

• Proven attendance record.
• Demonstrates understanding and complies with patient and staff safety policies and procedures that foster a safe and inclusive environment for all.

• Ability to perform the essential duties of the job.
• Effectively uses empathy in interactions with others.
• Demonstrates behaviours consistent with Mackenzie Health’s Commitment to Caring.
• Models behaviour that is aligned with the values of Mackenzie Health - Excellence, Leadership and Empathy.
• Commitment to providing an exceptional experience for staff and clients within a challenging and exciting health care environment.
• Excellent interpersonal and decision-making skills
• Strong organizational skills
• Ability to adapt to a changing environment and assume responsibility for own learning
• Demonstrated leadership skills and ability

Preferably, your profile also includes:

• Computer literacy required -Database management skills preferred
• Experience working with acute and rehab patients.
• Experience working with the elderly.
• Ability to speak a second language.

*You may be required to work at any site of Mackenzie Health

*Will be required to travel to the community within the York Region

Mackenzie Health is an inclusive and equal opportunity employer committed to providing accommodations for applicants upon request at any stage of the recruitment process in accordance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code.

We thank all applicants for their interest; however, only those under consideration for an interview will be contacted.