PositionPosition: Palliative Nurse Navigator (1.0 FTE) Reports To: Manager Specialized ProgramsPosition SummaryAs a key member of the Couchiching Family Health Team (CFHT), and an integral part of an interdisciplinary health care team, you will deliver nursing care in accordance with FHT policies and professional practice standards. The Palliative Nurse Navigator is a specialist in palliative care and is responsible for the planning, coordination and delivery of palliative and end of life care to patients and their families and caregivers.Working in collaboration with an interdisciplinary team, the Palliative Nurse Navigator will provide clinical and educational support and facilitate care connections across the health care sectors for clients requiring palliative care in the community. As well, you will provide expert clinical palliative leadership to support seamless, integrated care delivery. The Palliative Nurse Navigator will apply an anti-oppressive lens in supporting diverse patients, including those facing systemic barriers.Why Join UsJoin a collaborative, team-based primary care workplace focused on improving access and continuity of care in the community, and be part of a progressive organization advancing Ontario Health's Primary Care for All initiative.Roles and ResponsibilitiesScreen, prioritize and process client referralsConsult with Primary Care Practitioners and specialists and review client clinical information obtained through the Primary Care Practitioner and client health recordsProvide client-centred case management, including assessment, service coordination, and evaluation, and a direct report to the Primary Care Practitioner, specialist involved in client's careLink with community resources, particularly supportive care and palliative care facilities and services and share information to provide the best experience for the clientIn collaboration with the Primary Care Practitioner and other members of the interdisciplinary team, develop and discuss an appropriate individualized care plan with the client/family/caregiver based on best practiceRecommend and teach client's treatment protocols and education as requiredLiaise with other palliative care providers within the circle of care at palliative care rounds and provide home visits as required for integrated care delivery, adhering to the CFHT Home Visit Policy GuidelinesPalliative pain assessment and management to assist Most Responsible Primary Care Practitioner (MRPCPs) with treating pain effectively in the palliative and end of life setting in the home. Suggest and support the MRPCP with appropriate directions in order to properly treat painIndication to MRPCP what the patient's current Palliative Performance Scale (PPS)



is to alert the MRPCP to any changes that may need to be addressed to help improve Quality of Life (QOL)Implementing Edmonton Symptom Assessment Scale (ESAS) with every patient encounter to provide the MRPCP with an indication of what symptoms are paramount for the patient at any given time and assist the MRPCP with the appropriate treatment and avoid hospitalizationActively participate in staff, team and committee meetings, if appropriateParticipate in the development, planning and evaluation of treatment, education, counselling and health promotion activities of the FHTPromotion Activities of the FHTOf note: The CFHT palliative care coordinator does not routinely administer symptomatic medications; however, in circumstances where a patient is experiencing significant symptoms that may be managed using medications contained within the Pain and Symptom Relief Kit available in the home, the CFHT palliative care nurse may, based on clinical knowledge, skill, and judgement and within scope of practice, administer these medications in accordance with orders provided by the most responsible primary care provider (MRPCP). All interventions must be documented in the medical record accordingly.Work in compliance with Health and Safety laws adhering to safe work practices and procedures established by the CFHTOther duties as requiredOrganizational Nursing SupportAdapt to the staffing needs of the CFHT by assisting with Nursing responsibilities in other CFHT programs and services as requiredReportingPrepare quarterly reports and monitor daily statistical data to ensure statistics are reported to the Ministry of Health in a timely fashionAccurate and timely documentation into the Electronic Medical Record as per the CFHT Documentation Policy. Given the changing nature of health status within the Palliative Patient, however, priority must be given to recording details of sessions and documentation must be completed within 24 hours of the appointment.Professional DevelopmentMaintain and develop professional competence through ongoing professional developmentStay current and aware of opportunities to implement new, evidence-based methods of client assessment,



treatment and programmingMaintain and upgrade knowledge and skillsParticipate in clinical projects as requiredEducation/Specific Job RequirementsCurrent Basic Cardiac Life SupportCurrent membership and in good standing with the College of Nurses of Ontario (CNO)Current membership in Registered Nurses Association of Ontario (RNAO) preferredDemonstrated understanding of client-centred case management, including assessment, service coordination, and evaluationDemonstrated and comprehensive understanding of ethical decision-making principles, palliative care philosophy, and quality end of life care planningDemonstrated working knowledge of community resources, particularly supportive care and palliative care facilities and servicesDemonstrated evidence of sound organizational, prioritization, and conflict management skills with the ability to work well in stressful situationsExcellent communication, negotiation, teaching and interpersonal skills with the ability to work well with patients, families, all levels of staff and the communityDemonstrated ability to work well autonomouslyMaintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy ActFlexible to meet additional responsibilities as program demandsPositive attendance and work record essentialAble to work flexible hours including evenings if requiredIt is a condition of employment that you receive the necessary vaccinations to protect against infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental and publichealth authorities from time to timeExperienceDemonstrated clinical competence in nursing practice with 3-5 years recent experience working in a palliative care/oncology/hospice environment. Preference will be given to those candidates with foundations in oncology courses and CNA Palliative/Hospice Care certificationHighly experienced with physical assessment as well as competence in emotional assessment to assist MRPCP with developing an appropriate plan of care as per patient wishesRelevant community-based or lived experience working with palliative clients, their families, and/or caregivers may be considered an assetThe Couchiching Family Health Team supports diversity, equity and a workplace free from harassment and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection process and workplace. If you are contacted to participate in our recruitment process, please advise the interview coordinator of any accommodations. The CFHT has an Accommodation Policy and Procedure to ensure you have access to a fair and equitable process. While we thank all applicants, only those contacted for an interview will be acknowledged.Please submit cover letter and resume including position title in subject line to: [email protected] those selected for an interview will be contacted.Reviewed: Feb 2025Revised: June 2026

📌 Palliative Nurse Navigator (Ottawa)
🏢 Couchiching Family Health Team
📍 Ottawa