Registered Practical Nurse (RPN) OHT-N Supportive Attachment Nurse Navigation Program

# Summary 

# About the organization 

Community Health Centres of Northumberland (CHCN) opened in 2009 and continue to improve our programs and services to best meet the needs of our community. Our CHCN delivers primary care (family physicians and nurse practitioners), diabetes education, mental health and addictions counseling, geriatric outreach services, a memory clinic, dental care, and many health promotion and community development activities.  We focus on the frail elderly, people struggling with mental health issues and/or addictions, those unable to have even basic housing and food, the lonely and youth at risk.

# About the position 

Job Summary: 

The Registered Practical Nurse (RPN) plays an integral role in improving access to primary care for unattached patients across Northumberland County. Reporting to the Manager, Specialized Programs, the position combines administrative coordination, patient attachment activities, clinical intake and assessment, system navigation, and program support functions to facilitate timely and successful attachment to primary care providers.

Working collaboratively with the Community Health Centres of Northumberland (CHCN), Ontario Health Team of Northumberland (OHT-N), Ontario Health atHome Care Connectors, primary care providers, and community partners, the RPN collaborates with Ontario Health at Home’s Health Care Connect (HCC) program, Supported Attachment initiatives, and primary care onboarding activities.

The position serves as a central point of coordination for primary care attachment processes, provider engagement, intake and onboarding activities, community navigation, reporting requirements, and program administration. The incumbent utilizes clinical knowledge, organizational skills, and health system expertise to support equitable access, continuity of care, and positive patient and provider experiences.

Key Responsibilities:

Program Administration and Coordination

• Coordinate daily administrative functions associated with Health Care Connect and Supported Attachment initiatives.
• Manage schedules, appointments, meetings, correspondence, and documentation.
• Maintain program databases, records, filing systems, and tracking tools.
• Support communication and coordination among providers, staff, community agencies, and system partners.
• Monitor program deliverables, timelines, and action items.

Health Care Connect and Attachment Coordination

• Review Health Care Connect waitlist information and support local attachment planning activities.
• Collaborate with Ontario Health atHome Health Care Connect, Care Coordinators, primary care providers, and OHT partners to facilitate primary care attachment.
• Support provider outreach and maintain information regarding provider availability and attachment capacity.
• Monitor and support attachment activities and support achievement of organizational and provincial attachment targets.

Supported Attachment Clinical Activities

• Provide person-centered care to individuals being attached to a family physician or nurse practitioner. 
• Conduct initial intake, including health history, basic assessments, and identification of care needs within RPN scope. 
• Support a structured and welcoming onboarding process for newly attached patients. 
• Ensure required health history, screening, and information is collected and documented prior to first primary care visit. 
• Collaborate with primary care providers to support continuity and readiness for attachment.
• Support primary care providers with preventative care services, as required, including:
  • Women's Health: Demonstrates competency in women's health assessments, including performing cervical cancer screening (Pap Testing), and supporting preventative care in accordance with current clinical guidelines. 
  • Well-baby Care and Immunization: Provides comprehensive well-baby assessments, growth and developmental screening, and administers routine childhood immunization in alignment with the provincial immunization schedule and best practice standards. 

Key Competencies

• Person-centered care 
• Care coordination, navigation, collaboration and relationship building 
• Clinical assessment (within RPN scope) 
• Problem-solving & adaptability 
• Equity-focused practice
• Care Navigation & Coordination
• Act as a first point of contact between patients and primary care providers. 
• Identify to provider appropriate health and social support (e.g., chronic disease programs, mental health services, housing, income support) where required. 
• Promote equitable access to care by identifying and addressing barriers (e.g., transportation, language, system navigation). 
• Build and maintain strong relationships with community agencies and healthcare partners. 
• Participate in interdisciplinary team meetings and Ontario Health Team initiatives. 
• Contribute to a coordinated system of care that improves patient flow and attachment outcomes. 

Data Management, Reporting and Quality Improvement

• Maintain accurate and timely documentation and reporting.
• Collect, analyze, and report program metrics and performance indicators.
• Support reporting requirements related to Health Care Connect, Supported Attachment, Ontario Health Teams, and funding agreements.
• Participate in quality improvement initiatives focused on access, attachment, patient experience, and service delivery.
• Identify trends, barriers, gaps, and opportunities to improve program effectiveness.

Team Contribution & Professional Practice

• Work collaboratively within an interprofessional team environment. 
• Maintain professional standards in accordance with the College of Nurses of Ontario (CNO). 
• Ensure confidentiality, privacy, and safe practice in all aspects of work. 
• Participate in ongoing learning, communities of practice, and program development. 

Organizational Responsibilities:

• Treat all individuals with respect and value, contributing to a positive, respectful, and safe workplace
• Incorporate critical thinking practice and a collaborative interdisciplinary approach to problem solving, decision-making, and service delivery 
• Work in a manner that respects privacy and preserves confidentiality following all relevant policies. 
• Promote safety and seek to minimize risks to patients, staff, community partners, visitors, and CHCN property and reputation. 
• Collect and report statistical (quantitative and qualitative) information as required
• Incorporate and contribute to the Centre’s efforts for service in excellence and continuous quality improvement by identifying, implementing, and evaluating standards, policies, and practices to support best practices. 
• Participate as a team member in staff functions: program planning, team and inter-team meetings, all staff meetings and team building
• Adhere to all CHCN infection prevention and control policies, including screening protocols, enhanced infection prevention procedures, and use of personal protective equipment as required.
• Accept responsibility for assigned duties, meet established timelines, and seek clarification or support when workload or priorities are unclear. 
• Works in a manner that seeks to minimize risk to clients, self, the Centre and to staff.  Committed to safety, works in a manner that demonstrates responsibility for following the Centre’s safe work practices and works in compliance with the Occupational Health and Safety Act. Takes responsibility for and is expected to report and unsafe/at risk conditions as well as be accountable for their correction
• Communicates in a timely and positive manner with the Manager of Specialized Programs regarding job content, specific objectives and personal performance
• Identifies performance goals, objectives, and learning needs.  Identifies concerns in a timely manner and, in collaboration with the Manager of Specialized Programs, seeks resolution
• Participates in team-based care planning and clinic operations
• Contributes to the evolution of an NP-led rural access and attachment model
• Incorporates and contributes to the Centre’s efforts for continuous quality improvement by identifying, implementing and evaluating policies and practices to support best practice 
• Participates as a team member in all staff functions: program planning, team and inter-team meetings, all staff meetings and team building.
• Performs other duties as assigned.

# Qualifications

• Current registration in good standing with the College of Nurses of Ontario (CNO) as a Registered Practical Nurse (RPN). 

• Minimum 2–3 years of experience in primary care, community health, or a related setting. 
• Experience supporting vulnerable or complex patient populations is an asset. 
• Strong understanding of health system navigation and community resources. 
• Demonstrated ability to work independently in dynamic and non-traditional care settings. 
• Excellent communication, assessment, and interpersonal skills. 
• Proficiency with electronic medical records (EMRs) and digital tools. 
• Knowledge of health equity principles and social determinants of health.