Southlake is building healthy communities through outstanding care, innovative partnerships, and amazing people. We deliver a wide range of healthcare services to the communities of northern York Region and southern Simcoe County. Our advanced regional programs include Cancer Care and Cardiac Care and serve a broader population across the northern GTA and into Simcoe-Muskoka.

Our team of nearly 6,000 staff, physicians, volunteers, students and Patient and Family Advisors are committed to creating an environment where the best experiences happen. As a recognition of our commitment to quality and patient safety, we have received the highest distinction of Exemplary Standing from Accreditation Canada.

Job Summary

SCOPE (Seamless Care Optimizing the Patient Experience) is a quality improvement collaboration between hospital and solo primary care providers (PCPs). The SCOPE program’s primary goal is to support primary care providers by improving access to high-quality care for their patients. SCOPE creates a virtual care team for family practices and provides a single point of access to a comprehensive range of interdisciplinary supports. The role of the Nurse Navigator is to act as the bridge between the patients, family practices and interdisciplinary supports in order to remove barriers and increase wellness across all life domains. High levels of flexibility, problem solving, strong communication, and knowledge of the community served are required to be successful. SCOPE aims to help reduce avoidable ED visits, hospital re-admissions and to identify and improve gaps in care.

Primary Responsibilities

• Serve as a point of access to connect family physicians to appropriate community, clinical and specialized supports to address patient health concerns
• Establishes close relationships with primary care providers (PCPs) by visiting clinic’s or offices weekly to educate on SCOPE’s role
• Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care
• Maintain real-time and accurate records of patient status through care transitions
• Collect Data for research evaluation for each referral – Database Entry forms to be completed with each referral and submitted to the evaluation team on a weekly basis
• Assume a leadership role in influencing clinical practice and patient outcomes
• Collaborate with the broader health care team and community partners regarding complex and challenging patient care situations
• Initiate and participate in professional and organizational activities to improve and advance the SCOPE role
• Ensure timely access to appropriate diagnostic tests and referrals to specialized clinical professional across the episode of care
• Support and participate in ongoing program development and quality improvement initiatives. Create new pathways for complex patients that will require integrated care
• Respond to all calls and emails made to Scope Navigation Hub
• Triage and forward referrals to appropriate SCOPE contact (i.e. Internist, Nurse Navigator and HCCSS coordinator )
• 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
• Ensure that guidelines for high quality care are followed at every stage.
• Direct requests for Internal medicine consultations or medical work-ups to SCOPE’s Internist-On-Call
• Collect data for the evaluation of the SCOPE research protocol
• Attend Primary Care Project meetings, as required

Skills & Abilities

• Minimum of 3 years of experience within acute care and/or primary/community care
• 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
• Excellent interpersonal and decision making skills
• Strong organizational skills
• Ability to adapt to a changing environment and assume responsibility for own learning
• Computer literacy required -Database management skills preferred
• Demonstrates understanding and complies with patient and staff safety policies and procedures that foster a safe and inclusive environment for all.
• Demonstrated excellence in communication, both written and verbal
• Demonstrated problem assessment skills
• Demonstrated commitment to customer service and teamwork
• Demonstrated individual leadership skills
• Commitment to providing an exceptional experience for patients and families as well as other members of the healthcare team within a challenging and exciting health care environment.
• Demonstrated commitment to, and understanding of the principles of diversity, equity and inclusion
• Models behaviour that is aligned with the values of Southlake Regional Health Centre.
• Always with compassion
• Power of many
• Serve with purpose
• Every voice matters

Qualifications

• R.N. certificate of registration from the College of Nurses of Ontario required; BScN required
• Current registration with the College of Nurses of Ontario

As a condition of employment, you are required to submit proof of COVID-19 vaccination to the Hospital’s Occupational Health and Safety department. Successful candidates will be required to submit proof of COVID-19 vaccination (two doses) from the Ontario Ministry of Health website or other authorized source directly to the Occupational Health and Safety department. In the event that you are unable to be vaccinated as a result of a ground protected under the Human Rights Code, you may submit a written explanation of the ground and any supporting documentation to determine if you are exempt from this requirement to the recruitment team. A recruitment representative may follow up with you for further information if necessary.

At Southlake, we are committed to fostering an inclusive and accessible environment. We are dedicated to building a workforce that reflects the diversity of the community in which we live and serve, including those with disabilities. Southlake is committed to providing accommodations in all parts of the hiring process. If you require an accommodation, we will work with you to meet your needs.

It is the responsibility of all Southlake employees to work in a safe manner and promote health and safety in the workplace.