Description
SUMMARY OF THE POSITION
Reporting to the Director CMC, the incumbent contributes to the planning, organization, coordination and support for the holistic multi-disciplinary approach in the delivery of integrated Primary Care Services, of the Community Miyupimaatisiiun Center (CMC).
The incumbent collaborates with the Director of the CMC, the coordinators of Extended Care and Current Services, in order to provide healthcare to the population. The incumbent serves as a liaison, coordination and support point for all managers of the CMC Services. These responsibilities are for the population for preventative and curative health care, infectious diseases, mental health and social services.
This role also requires a comprehensive approach that integrates patient education, routine monitoring, medication management, lifestyle modifications, and relationship based coordinated care to enhance health outcomes and promote overall well-being.
This position is being posted as part of the ongoing transition toward the NISK model of care. While the model will be implemented gradually, this role will support the preparation and alignment of services as the transition unfolds.
SPECIFIC FUNCTIONS
1. Ensures the responsibilities for programming of services delivered in the Community Miyupimaatisiiun Center according to the CBHSSJB’s clientele approach and Cree culture with an integrated approach. This includes:
a) Chronic Disease Management and Prevention; Oversees the delivery of diabetes prevention and management services. This role ensures that interdisciplinary teams provide culturally safe, integrated, and community-centered care aimed at reducing the impact and prevalence of diabetes across Eeyou Istchee.
b) Primary and Preventative health care; Primary health care delivers essential, community-based medical services, encompassing disease prevention, diagnosis, treatment, rehabilitation, and palliative care, while ensuring accessibility and addressing broader health determinants. Preventative health care focuses on reducing disease risks through proactive measures such as vaccinations, screenings, health education, and lifestyle interventions.
c) Adult and Elderly follows up; Programs provide access to healthcare, including vaccinations, screenings, and referrals to specialists, ensuring physical well-being. Services may include education, mental health support, and resources for families facing challenges, such as poverty or housing instability.
d) Psychosocial support to families in difficulties; referral & liaison services; ensuring that community workers effectively deliver psychosocial support to families in need; effectively deliver short term and solutions-focused psychosocial services, manage referrals and liaison services with extended care teams ensuring continuity of care and service delivery.
e) Liaison/Wiichihiituwin Patient Services: Liaison services in primary care facilitate seamless coordination among healthcare providers, patients, and community resources, ensuring efficient care delivery, equitable access, interdisciplinary collaboration, cultural competency, and data-driven service improvements to enhance patient outcomes and healthcare system effectiveness
2. Contributes to the leadership, and the planning, organization, coordination and support for the development and programming of the Services with the incorporation of such policies, procedures, protocols and tools:
a) Collaborates with key stakeholders to ensure seamless integration of primary care services. Enhances accessibility, effectiveness, and continuity of care through multi-disciplinary engagement with Miyupimaatisiiun extended care teams.
b) Ensures program (service) orientation, planning, organization, coordination and support clinical Services, through integrated co-management relationships with the various managers;
c) Contributes to ensuring the design, development, organization, distribution, updating and evaluation of service and program planning, and that it is complete for operational use, and; includes clinical, service and program objectives, policies, protocols, and employee support tools, and; results in Program Manuals and Management Guidelines that support a quality assurance.
d) Collaborates with others according to their roles. Contributes to program design, support and planning for the integrated care services and multidisciplinary team design, continuity and complementary of the Unit activities with those of the other CMC Units, and other resources within the community, organization and externally.
3. Provides advice, coordination and assistance to other Coordinators for specific aspects of operational management, as requested or directed.
4. Advises the Director of the CMC on health, social, allied and clinical matters.
5. Collaborates in the planning, organization, coordination, and support for the development and integration of the professional orders and practice standards into the tactical level of services planning, and the incorporation of such in policies, procedures, protocols and tools.
6. Ensures the circulation, application and compliance with the clients and their families’ individuality, privacy and rights; code of ethics and confidentiality. Ensures that the confidential data regarding the clients are respected.
7. Contributes in the implementation of the policies regarding access to client files. Contributes to the development of an effective system for the preparation of intervention plans, record keeping (client file) and the maintenance of various records.
8. Collaborates in the development of clinical and management information systems that include MYLE, CDIS, Care4, EPIC and other systems that will be implemented.
9. Ensures that the programs and services provided are based on respect and autonomy of individuals and communities and respond to their bio-psycho-social needs as well as cultural and spiritual needs in the spirit of Nishiiyuu.
10. Supports the implementation and monitoring of Quality Assurance by collaborating with the DPSQAs and DMAS, in the design, evaluation, and inspection processes. Assists the DPSQA in planning, organizing, and integrating professional practice standards into service delivery, policies, and procedures.
11. Supports community initiatives that enhance safety and foster a thriving environment with a forward-thinking approach and a commitment to positive impact, they ensure ongoing collaboration and strong partnerships, this includes working closely with all community and regional stakeholders
12. Patient-Centered Care; Focuses on building strong, trust-based relationships with patients, ensuring personalized care that respects individual needs, values, and preferences.
13. Fosters multidisciplinary collaboration within a diverse care team, including physicians, nurses, community workers, PCCR and medical secretaries and other healthcare professionals, to provide holistic and coordinated services.
o Ensures seamless continuity of care during healthcare transitions by providing comprehensive support to patients as they navigate different stages of their care pathway.
14. Facilitates smooth coordination between primary care providers, specialists, and extended healthcare services to prevent gaps in care.
15. Oversees long-term treatment plans, ensuring patients receive consistent monitoring, medication management, and lifestyle guidance tailored to their specific conditions-Provides guidance and support to patients as they navigate extended healthcare services, including specialist care, diagnostic evaluations, hospital-based treatments, and community health programs.
16. Ensures a seamless care journey by facilitating access, coordination, and continuity of services tailored to individual needs.
17. Emphasizes preventative and proactive care through early intervention, health promotion, and disease prevention to enhance patient well-being and long-term health outcomes.
18. Integrates culturally responsive healing-informed care and recognizes the impact of social determinants of health-such as socioeconomic status, education, environment, and access to resources-on overall well-being. Works proactively to identify and address barriers to care, including language accessibility and systemic inequities, ensuring that all individuals receive equitable, inclusive, and patient-centered support.
19. Ensures comprehensive case management practices and supports the development of care plans tailored to patient needs, advocating for their health goals while ensuring integrated support across services.
20. Ensures the efficient people management of the Unit in part by being directly responsible and accountable for the supervision and management of employees and overall management of the Unit.
21. Ensures the financial management of the Unit in part by monitoring quarterly budget reports provided by the Financial Resources and reporting on any financial issues related to the Unit.
22. Directly supervises the planning, procurement, storage, and control of materials needed for the Unit to ensure efficient operations and meet operational needs, including overseeing inventory management, purchasing, logistics, and quality assurance.
23. Contributes to the accomplishment of the strategic regional plan of the CBHSSJB through collaborative partnerships, and involvement with the organization’s management, staff and various external partners.
REQUIREMENTS
Education and experience
• Bachelor degree in Nursing and member of the O.I.I.Q;
• Five (5) years of experience in service/program planning, management or supervision in primary care services and multidisciplinary team setting;
• An expertise in a relevant area such as in community health, is an asset.
Knowledge and abilities:
• Good knowledge of the MSSS network, regulations and programs for General and Primary Care Services and nursing practice in a Community Health & Social Service Center (CLSC) and current services;
• Good knowledge of and experience with acute and current nursing, health and social services in a first-line community health clinic and hospital ambulatory unit, and its related theory, practice, current issues and trends, and program planning and supervision, including the development of policies and program manuals and quality assurance systems;
• Good knowledge of programs and services related to client bio-psycho-social needs as well as cultural and spiritual needs;
• Good knowledge of pre-hospital services, childhood related health care, and community health prevention and promotion approaches is an asset;
• Good knowledge of multidisciplinary team functioning and leadership;
• Ability to manage the planning and development of new services and programs;
• Knowledge of, or ability to grasp the issues and context related to First Nation health and social services;
• Knowledge of Eenou/Eeyou Miyupimaatisiiun (traditional methods) healing practices;
• Ability to apply Eenou/Eeyou culture, values, traditions and teachings into programs and services;
• Knowledge of Cree culture;
• Northern health care experience is an asset;
• Good interpersonal communication, clinical and community health leadership and respectful teamwork skills;
• Ability to effectively collaborate with line managers in a matrix organization;
• Excellent communication skills, both written and presentation;
• Methodical, organized, autonomous, flexible, and ability to multi-task.
LANGUAGE
• Fluent in Cree and English;
• Fluency in French is an asset.
OTHER
• Includes on-call periods;
• Willing to travel.
