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Cardiac & Pulmonary Rehabilitation ONA Paramedical

Salary Information

$36.84 - $63.62 / hour (rate to be determined based on applicable Collective Agreement)

Application Closing Date

October 28, 2026

KEY FUNCTION:

Oversee transitional care coordination and patient navigation to support community transitions for patients living with Chronic Obstructive Pulmonary Disease (COPD).

REPORTING:

Under the general direction of the Clinical Manager, Integrated Chronic Pain Program, OBIRS, CDSMP, HAVEN/Hemophilia/Hemoglobinopathy, Cardiac and Pulmonary Rehabilitation and Outpatient Neurological Rehabilitation.

DUTIES:

- Coordinate seamless transitions of care for COPD patients discharged from acute care settings.
- Collaborate with primary care providers, specialists, home care agencies, and community programs to support coordinated care delivery; ensure patient goals and preferences are documented and communicated appropriately.
- Ensure timely connection to Pulmonary Rehabilitation and outpatient follow-up services.
- Assess condition changes and medication effects and relay relevant information to physicians and team members.
- Review discharge plans and identify potential gaps or barriers to successful community transition.
- Serve as a central resource hub for COPD patients and caregivers.
- Assist patients in navigating healthcare services and community resources.
- Connect individuals to appropriate support services, including home care, smoking cessation programs, respiratory equipment providers, transportation services, financial assistance programs, and social supports.
- Provide individualized education on COPD disease management,



symptom recognition, inhaler techniques, oxygen therapy, and lifestyle modifications.
- Reinforce discharge instructions and treatment plans to improve understanding and adherence.
- Support patients in developing self-management skills and confidence in managing their condition at home.
- Promote participation in Pulmonary Rehabilitation and evidence-based chronic disease management programs at local and regional level.
- Conduct scheduled follow-up calls following hospital discharge to assess patient status, identify concerns, and reinforce care plans.
- Monitor symptoms, treatment adherence, and functional status during the post-discharge period.
- Identify early warning signs of exacerbation and facilitate timely intervention.
- Ensure follow-up appointments, diagnostic testing, and specialist consultations are completed as required.
- Utilize established clinical pathways and escalation protocols to facilitate timely intervention by appropriate healthcare providers.
- Communicate urgent concerns to physicians, respiratory therapists, nursing teams, or other members of the care team as required.
- Initiate and support early conversations regarding goals of care, advance care planning, and future healthcare preferences.
- Provide education regarding advance directives and available supportive care resources.




- Work closely with inpatient Medicine, Respiratory Therapy, Pulmonology, nursing, and allied health teams to support coordinated patient care.
- Participate in multidisciplinary rounds, case conferences, and care planning meetings as required.
- Maintain accurate documentation and care coordination records in the electronic medical record.
- Track program metrics such as readmission rates, emergency department utilization, follow-up completion, and patient engagement.
- Contribute to quality improvement initiatives focused on care transitions, patient outcomes, and service effectiveness.
- Evaluate patient care and satisfaction on an ongoing basis and formulate solutions for improvement.
- Determine and align improvement projects with HSN’s Strategic Plan; monitor and adjust to achieve goal outcomes.
- Contribute to learner development by providing academic support, mentorship, preceptorship and supervision as required.
- Participate in education and training specific to current, relevant federal and provincial health and safety legislation, standards and guidelines.
- Educate and promote health, safety and wellness in the work place.
- Represent the department or program on various committees and in meetings as required.
- Perform other duties as required.

QUALIFICATIONS

EDUCATION AND TRAINING:

- Current Certificate of Registration in positive standing with the applicable regulatory college, as a Registered Nurse (RN), Occupational Therapist (OT), Physiotherapist (PT), Masters of Social Work (MSW), Respiratory Therapist (RT), Kinesiologist (Kin), Dietitian (RD), Speech Language P

📌 Open Affiliation (Greater Sudbury)
🏢 Hsnsudbury
📍 Greater Sudbury