The Kootenay Boundary is undergoing primary health care transformation with the establishment of a Primary Care Network that will achieve (among other things):

• Increased attachment and access to primary health care services,
• Wrap around team based primary health care, and
• Culturally safe, respectful and agile primary health care.

A PCN is a network of local primary care service providers designed to meet patients primary care needs. In a PCN, family physician practices, nurses and nurse practitioners, allied health and health authority service providers, and Aboriginal health coordinators form a partnership in which they work together as a team to provide health care services.

The Primary Care Network in the Kootenay Boundary is managed by tri-partate governance between Interior Health, Kootenay Boundary Divisions of Family Practice and Aboriginal Partners.

The Kootenay Boundary Aboriginal Services Collaborative was established in 2019 and exists to provide support and advise on the above noted attributes of the Primary Care Network. The KBASC has a vision to support the wellbeing of Aboriginal people living in the region. The Collaborative includes members from Ktunaxa, Syilx and Metis Nations, as well as representatives of the urban Aboriginal population.

CONTRIBUTION TO THE REGIONAL VISION

The Aboriginal Patient Navigator is part of the interdisciplinary team of professionals dedicated to the well-being of Aboriginal people in the Kootenay Boundary region and is managed by the Circle of Indigenous Nations Society (COINS). In a PCN, family physician practices, nurses and nurse practitioners, allied health and health authority service providers, and Aboriginal health coordinators form a partnership in which they work together as a team to provide health care services.

The Navigator position is a resource for the Aboriginal patient, the health care providers, families and community to support services and decisions towards wellness and to ensure care is delivered in a culturally inclusive and humble way. With proven ability to be innovative, flexible, organized and responsive to the needs of patient, the Navigator ensures care is culturally safe and respectful.

POSITION SUMMARY

Aboriginal Patient Navigator provides referral services to support for Aboriginal patients and promotes and is a resource for culturally safe, inclusive care among health care providers. The APN assists health care teams with case planning and discharge planning as they relate to liaising with Aboriginal service providers.

The APN mandate is to Assist Aboriginal people with access to health services. As a personal guide, the Navigator is there to help the patient and family through their health care journey before being admitted to and/or released from hospital. The APN acts as a bridge between Aboriginal patients, their community and the health care system, through consultation and referral services.

COMMUNITY IMPACT

The Patient Navigator position is both privileged and empowered to significantly influence and change the health care reality for Aboriginal people through proactive, responsive action that supports, cares for and protects human capacity, most particularly those in the acute health care system. This position preserves the rights and dignity of those who are in a health environment that is unfamiliar, that is not culturally relevant, and ensures care and safety in transitions into and out of the acute system.

Helping individuals and their families negotiate complex systems, build solid support networks, cope with stress, and strengthen or restore their ability to self-manage.

PROBLEM SOLVING

● The requirement is to plan, prioritize, organize on a daily basis; being prepared for such planning to be overridden by critical / emergency situations. This role requires the constant review of priorities. This is done on an individual basis and within the context of the care team for each client. There is a continual challenge in this area due to shifting needs and urgencies, emergencies, reporting requirements, unannounced visits or telephone calls.

● Has the autonomy and authority to make decisions within established criteria, that pertain to the needs of the Aboriginal patient but is required to consult with the supervisor on complex cases, financial supports, and any other significant decisions to ensure all factors have been considered.

● Responsible for prioritizing workload based on level of need and/or risk to the public, the staff and the service recipient.

● Administrative problems and queries tend to be repetitive, cyclical or follow a regular pattern, however situations can be sensitive, requiring adaptation for the circumstances, requires discernment and ability to know if needs to be escalated to Supervisor for discussion and action.

● Handling queries for information and redirection to appropriate person/agency.

● Follows COINS policy and administrative directives / procedures (sometimes providing instructions or rationale for these policies).

● Problem resolution: identification of details, subtleties and facts; discernment of policies and/or precedents; resolutions with awareness of equity, precedence, consequences, repercussions, liabilities.

● The quality of the knowledge and administration that the position provides affects the efficiency and accuracy of operational policies and administrative systems, the thoroughness and relevance of procedural guidelines. The position also protects individuals and COINS from harm, vulnerability, undue risk and liability.

● Contributing to the future human capacity of the Aboriginal community in the Kootenay Boundary.

● Understanding of services, policies, and laws around hospital services.

CONTACTS / COMMUNICATION

Provide information to clients by telephone, in written form, e-mail or in person.

Contact key individuals inside and outside of when necessary. Work with a team-based approach with the Aboriginal Health Coordinators and other health care staff to provide wrap around services to Aboriginal patients. Observe, receive and obtain information from all relevant sources in support of Aboriginal patient’s care and well-being.

● Excellent communication skills, including listening to others, process information and be effective in written, oral and presentation skills; ability to express complex issues, concerns, situations in an easily understandable way;

● Ensure the voice of the marginalized is heard throughout the acute system and by attending community events, interviewing service recipients to center their experiences of seeking and receiving care;

● Ensure service providers understand the importance of Aboriginal protocols, expectations, and traditional ways as it relates to the well-being of the patient.

The quality of the knowledge and guidance provided affects the efficiency and accuracy of policies and administrative systems, the thoroughness and relevance of procedural guidelines and the competent management of programs.

COMPLEXITY

Hold in care vulnerable people; preservation of dignity and respect; advocacy for marginalized individuals; enhancement of family, relationships, culture, with integrity, honesty and creativity through the oversight of services. The position also protects individuals and COINS from harm, vulnerability or liability.

Planning, prioritizing and organizing vary according to the nature and volume of service provided. Some tasks are repetitive and are predictable. Other tasks have more flexible time lines. This position requires knowledge in a variety of areas. Frequent interruptions and crises occur requiring the ability to deal with unexpected events. Work must be reprioritized in light of interruptions, taking into account the extent to which many tasks must be integrated into the work plans of others. Multi-tasking, the ability to adapt and readjust with immediacy is a critical part of this role.

Establish and discern priorities considering the breadth of the position; availability to organization on a wide variety of functions; being culturally sensitive and aware.

In every aspect of this positions role, strategic thinking applies: what can be done to best meet this particular client’s needs; what are the vulnerabilities and liabilities. There is the added complexity of having to consider, in each human circumstance, what the implications of both short and long term interventions could be.

● As the liaison between many groups, this requires tact and diplomacy due to conflicting priorities, political nature and level of decision making.

● Anticipate reactions and outcomes and prepare for these in advance to ensure a smooth flowing cycle.

● Prioritize issues and work on many projects at the same time to ensure that the tasks are completed efficiently and effectively.

CONTRIBUTIONS AND RESPONSIBILITIES

Coordinates and assists Aboriginal persons with medical appointments; provides supportive hospital visits; assists and supports with quality care issues. The Navigator supports discharge planning process to facilitate the timely ease of transition to and from acute care (hospital) within the communities.

● Liaise between the patient and Aboriginal agencies, health professionals and supports to home community

● Provide link for Aboriginal people accessing acute health services and acts as a contact if they require support

● Assist patient with completing paperwork related to their health care needs

● Facilitate patient understanding of medical conditions, impacts and discharge planning by acting as translator, or facilitating language support, when required

● Assist health care professionals to explain to Aboriginal patients and their families the patient’s diagnosis, treatments and procedures

● Advocate for Aboriginal patient / families in health care facilities and service agencies

● Refer / network with other health care professionals for services and professionals both in Interior Health facilities as needed.

● Provide culturally relevant information to patients, families and acute health care team

● Provide educational and informational sessions on Aboriginal health practices and resources, as well as supporting development of cultural competency in health care team, often in partnership with Aboriginal Health Coordinators

● Provide access to and help to keep current culturally appropriate brochures and pamphlets identifying local resources and emergency contact numbers

● Assist in ensuring spiritual care of Aboriginal patients, assist with links to community when necessary or requested

● Participate in review of treatment plan and weekly discharge planning round as required

● Support / promote family meetings when requested. Provide awareness of available services

● Maintain relationships and links with Aboriginal Elders and organizations, provide patients with linkages to broader supports in other communities

QUALIFICATIONS:

Bachelor degree in Social Science, Social Work or a combination of education and relevant experience.

Required Skills, Knowledge and Experience

● 3-5 years’ recent experience working with diverse clients with health issues and social barriers

● This includes 2 years’ experience in direct service, community-based delivery systems and working with Aboriginal people

● Valid BC driver’s license

● Reliable vehicle (with business insurance)

● Criminal record check (including vulnerable sectors check)

● Effectively communicating with a wide range of people, from family members to community services.

● Broad knowledge of case management including strengths-based, solution-focused practice and grass roots approach within a client centered care model for clients with complex / cultural care needs

● Ability to promote client focused care that demonstrates care for and with clients and families, sensitive to diverse cultures and preferences, client advocacy and social justice concerns

● Comprehensive knowledge of other health disciplines and their role in client care

● Ability to work respectfully amongst many levels of hierarchy and administrations in both Aboriginal and non-Aboriginal environments

● Demonstrated ability to work independently and as a team member

● Demonstrates ability to problem solve using sound judgment in applying critical thinking skills within safety limits of client care

● Demonstrated ability to organize work, set objectives and establish priorities; manages time and resources, implements activities to promote cooperation among interdisciplinary teams and collaborates across disciplines

● Understanding of Aboriginal health challenges

● Willingness to learn and increase knowledge of local Aboriginal context in the Kootenay Boundary region

● Excellent communication skills, both oral and written

● Ability to deal with others effectively; and have strong interpersonal skills

● Commitment to ongoing professional development: maintain professional practice growth and knowledge to reflect current standards of practice

● Proficient computer skills with Microsoft Office and Adobe; navigating and accessing relevant online information (e.g. government forms)

● Proven ability to work well under pressure; particularly during stressful situations

● Extensive knowledge of Aboriginal issues both historical and current in British Columbia

● Knowledge of ethics and professional approaches in resolving ethical dilemmas

● Be a positive community role model

● Work in ways which empower and build capacity among individuals and communities

● Ability to work collaboratively and effectively with other staff as well as other inter-disciplinary partners in both the Aboriginal and non-Aboriginal environments

● Commitment to the capacity of individuals and communities to promote their own health and well-being

● Ability to ensure one’s own and clients’ safety

● Ability to deal effectively with conflict and apply dispute resolution and problem solving and negotiating skills in an effective and problem-solving manner

● Problem solving skills and strategies – ability to engage individuals presenting strong emotions and at times resistance to the involvement of service providers

● Willingness to analyze approaches used with families, to learn from mistakes, and to explore alternative strategies to working with families

● Understanding of drug and alcohol related issues

● Preferred to have ASIST, Non-Violent Crisis Intervention and basic first aid certifications.

● Ethical conduct and responsibility: sets a positive example and fulfills responsibilities with the highest diplomacy of integrity, ethics and professionalism. Must be discreet with sensitive confidential information.

Background Information – Health Outcomes – Aboriginal People:

● Despite the undeniable progress in closing health disparity gaps between Indigenous and non-Indigenous peoples, much remains to be done.

● The Truth and Reconciliation Commission has developed 94 Calls to Action, with six focused on health.

● The United Nations Declaration on the Rights of Indigenous People Articles 23 through 25 address the right to be involved in and determine priorities with health planning, the right to traditional health practices, and the right to equal access to highest attainable standard of physical and mental health.

Article 23 Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.

Article 24 1. Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services.

Article 24.2. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right.

● On February 12, 2019, the British Columbia government announced plans to introduce legislation that implements the United Nations Declaration on the Rights of Indigenous People (UNDRIP) (the Legislation), as part of the provincial government’s reconciliation objective. On October 24, 2019 the Province of BC and the First Nations Leadership Council introduced Bill 41 into the Legislative Assembly to move this legislation forward.

● The Missing and Murdered Indigenous Women and Girls Inquiry has identified 231 Calls to Justice, with 16 focused on health and wellness directed to government and health and wellness services providers.

● In November 2020, the In Plain Sight Report, authored by Mary Ellen Turpel-Lafond, was published with 24 recommendations to address systemic racism and discrimination in the BC Health care system. The report provided evidence that Indigenous people in BC are receiving services that are skewed away from primary, preventative care, and pushes them to secondary or tertiary care and treatment.