The Chatham-Kent Family Health Team (CKFHT) is a cooperative team of professionals including Physicians, NPs, Nurse Educators, Dietitians, Pharmacist, Occupational Therapist, Social Workers, Chiropodist, a Health Promoter, Certified Respiratory Educator and Diabetes Education Team. The CKFHT is located on five sites across the municipality of Chatham-Kent - Chatham, Dresden, Ridgetown, Wallaceburg and Blenheim. The CKFHT currently has ~35,000 rostered patients.

The Chatham-Kent Family Health Team is a health care organization “committed to working in partnership with individuals, families and community groups to optimize the health and well-being of our residents and communities within the municipality of Chatham-Kent.

Supported Attachment Coordinator

The CKOHT and its partners are aligned with the province’s goal of attaching 100% of the population by 2029. In doing so, the priority focus of the Supported Attachment Coordinator is to support patients in getting attached to a primary care provider in Chatham-Kent.

Role Purpose

The Supported Attachment Coordinator supports individuals who are unattached to primary care by providing individualized navigation, coordination, and advocacy. The role focuses on reducing barriers to attachment and supporting successful, sustainable connections to primary care and community services.

The Chatham-Kent Family Health Team is seeking a motivated, equity-driven healthcare provider to support the implementation of the Chatham-Kent Ontario Health Team’s Primary Care Access and Attachment Plan. This role plays a key clinical liaison function between patients and primary care providers, supporting patient matching, rostering and onboarding into primary care teams.

Key Responsibilities

Patient Identification & Engagement

- Identify unattached patients through referrals,



data sources, and community partners.
- Conduct patient-centered intake assessments to understand health needs, social circumstances, preferences, and barriers to attachment.
- Provide interim referrals and navigation to care for patients waiting for a primary care provider

Attachment Coordination

- Act as a liaison between patients, primary care providers, clinics, and system partners to facilitate timely and appropriate attachment.
- Match patients to primary care providers where possible, considering patient needs, complexity, geography, and provider capacity.

System Navigation & Collaboration

- Help patients navigate health and social services while awaiting attachment, including referrals to interim or wraparound supports as needed.
- Support warm handoffs to primary care teams to promote continuity of care
- Work closely with primary care teams, OHT partners, Home and Community Care, hospitals, and community organizations.
- Participate in cross-sector case discussions and care planning for patients with complex needs.
- Contribute to system-level problem solving to improve attachment pathways and processes.

Documentation & Reporting

- Maintain accurate, timely documentation of patient interactions, clinical assessments, outcomes, and attachment status.
- Track progress and outcomes related to attachment efforts to support quality improvement and reporting.
- Identify trends, gaps,



and barriers to inform system planning and pathway development.
- Efficient in Microsoft Excel and experience using Electronic Medical Records (EMR)

Core Competencies

- Patient-centered and trauma-informed practice
- System navigation and coordination
- Collaboration and partnership development
- Problem-solving and adaptability
- Data-informed practice and documentation

Qualifications

- Registered Nurse (RN), or Bachelor of Social Work (BSW), or Masters of Social Work (MSW)
- May be required to submit to annual TB and rubella screening
- CPR Certification and First Aid Certification as required
- Must be fully vaccinated (COVID-19)
- Hold a valid driver’s license and have a reliable vehicle to attend various primary care teams across Chatham-Kent
- Ability to work independently and collaboratively in a fast-paced, evolving environment.
- Bilingual or multilingual abilities are considered a strong asset

Required Knowledge and Experience

- Minimum 2 years of experience in primary care, community health, care coordination or health system navigation
- Familiarity with primary care electronic medical records (ie TELUS PS Suite, Accuro, etc)
- Knowledge of primary care systems, community resources, and health system navigation.
- Excellent understanding of the Ontario health care system, primary care delivery models, and solid understanding of local health issues, priorities and needs
- Demonstrate experience working independently across diverse care settings
- Experience supporting process design or program evaluation is considered an asset
- Experience working with vulnerable or complex populations, including those facing social determinants of health challenges.
- Strong c

📌 Supported Attachment Coordinator (Chatham-Kent)
🏢 Chatham-Kent Family Health Team
📍 Chatham-Kent