Job Description

Be a key part of the Community Integration and Primary Health Care Program by helping patients with complex health and social needs transition seamlessly from hospital to home. As a Halton@Home Patient Care Navigator, you’ll collaborate with an interdisciplinary team, provide compassionate care, and ensure that patients receive the right support at the right time. Your work will directly impact patient outcomes, reduce hospital readmissions, and contribute to a strong, community-focused health care system.

What You’ll Do:

- Coordinate Transitions to Home: Identify and assess patients eligible for the Halton@Home Program, ensuring timely discharge and smooth transitions from hospital to community care.
- Create Patient-Centered Care Plans: Develop, implement, and monitor personalized care plans in collaboration with patients, families, and our dedicated health care team.



Recommend and facilitate the multi-disciplinary supports needed to meet the patient's needs in the community.
- Advocate for Patients: Act as a liaison between patients, families, and community service providers, ensuring they have the resources and support needed for a successful recovery at home. Monitor service delivery and follow up after discharge to identify and address opportunities.
- Contribute to Program Growth: Share your insights and ideas to help evolve the Halton@Home Program, improving patient care and community resources through continuous feedback and collaboration.
- Collaborate Across the Community: Build solid relationships with community organizations, primary care providers, and home care services to ensure a coordinated, patient-focused approach to care.

📌 Halton@Home Patient Care Navigator (Oakville)
🏢 Halton Healthcare
📍 Oakville