Indigenous Transitions Facilitator - Inclusion

Requisition
104966
-Posted
10/27/2026

- Professional non-management

Department: Inclusion (People Services)

Position Number:

Hours of Work: Full-Time Position, Days

Union: Non-Union

Location: Kingston Health Sciences Centre sites

The Indigenous Transitions Facilitator is responsible for supporting Indigenous patients, families, and caregivers in navigating health and social service systems and accessing coordinated, culturally safer care across the care continuum. As an Indigenous health resource, who works across multiple programs and in the broader community, the Indigenous Transitions Facilitator promotes Indigenous health equity through advocacy, partnership development, and organizational capacity-building in support of culturally safer care and reconciliation.

Working collaboratively with patients, families, caregivers, interdisciplinary care teams, Indigenous communities, and community partners, the Indigenous Transitions Facilitator serves as a bridge between hospital and community services, reducing barriers to care and connecting individuals to comprehensive wraparound supports that address physical, emotional, mental, social, and spiritual needs. Through system navigation, care coordination, transition planning, caregiver engagement, and relationship-building, the role promotes equitable, person-centred care grounded in Indigenous perspectives of health, wellness, and healing.

• Respond to referrals from hospital care teams and serve as a key contact for Indigenous patients and families during discharge planning and care transitions.
• Coordinate services that help patients navigate and move safely between hospital, primary care, community services, long-term care, Indigenous health services, and provincial and federal programs.
• Collaborate with patients, families, caregivers, and care teams to develop discharge plans, involving caregivers early to identify education and support needs.
• Support medication reconciliation and help patients and caregivers understand medications, treatment plans, and follow-up care.
• Assess eligibility for home care and community programs, share information on available services, and coordinate with partners such as First Nation Home and Community Care, Jordan's Principle, and Non-Insured Health Benefits (NIHB).
• Maintain timely, accurate documentation in accordance with organizational, professional, privacy, and legislative requirements.
• Contribute to improving discharge planning processes and transition supports across the organization.

• Advocate for equitable access to services and identify barriers related to healthcare, social services, funding, transportation, housing, or other supports.
• Connect patients and families with Indigenous community resources, cultural supports, traditional healing services, Elders, and Knowledge Keepers when requested.
• Help patients access benefits and funding programs, and coordinate supports that address physical, emotional, mental, social, cultural, and spiritual needs.

• Build and maintain positive relationships with Indigenous communities, organizations, Elders, Knowledge Keepers, healthcare providers, and community agencies.
• Act as a link between hospital teams and community partners to strengthen services and support smoother transitions between hospital and community care.

• Provide guidance to staff and care teams on Indigenous health resources, community services, and culturally safer approaches to care.
• Share knowledge of Indigenous perspectives of health, wellness, and healing, and participate in initiatives that advance…