Triage/Care Navigator

Triage – Care Navigator

Program: HART Hub

Reporting To: Program Manager, HART Hub

Type: Full-Time Contract until March 31, 2028

Hours of Work: Monday to Friday, 8:30 a.m. – 4:30 p.m.

Position Summary

The Triage – Care Navigator is an on-site member of the HART Hub team who serves as a key point of contact for individuals accessing HART Hub services. Working collaboratively with Peer Support, Outreach, and other interdisciplinary team members, the Triage – Care Navigator identifies immediate and longer-term client needs and assists individuals in navigating health, housing, income, identification, treatment, justice, and social service systems.

The Triage – Care Navigator completes initial assessments, coordinates immediate supports, assists clients with applications and essential documentation, facilitates referrals and warm transfers, and provides ongoing navigation, advocacy, accompaniment, and follow-up as required.

Using harm-reduction, trauma-informed, culturally safe, strengths-based, and client-centred approaches, the Triage – Care Navigator works to reduce barriers to services and support clients toward long-term stabilization, treatment, wellness, and permanent housing.

The role also acts as a resource to HART Hub staff by maintaining current knowledge of available community programs, services, eligibility requirements, and access pathways.

Cultural Commitment

HART Hub honours the spirit, dignity, and resilience of our clients and communities by integrating Indigenous ways of knowing, being, and doing into all aspects of care.

The Triage – Care Navigator walks alongside each client throughout their healing and wellness journey, offering compassion, accountability, advocacy, and hope within a culturally grounded, community-based environment. The position demonstrates cultural humility and supports equitable access to services for Indigenous clients, including knowledge and navigation of Indigenous-specific programs and resources.

Primary Goal

To reduce barriers and guide clients toward long-term stabilization, appropriate treatment and supports, wellness, and permanent housing through coordinated navigation, advocacy, and connection to appropriate community resources and services.

Key Responsibilities

Assessment & Identification of Needs

• Conduct initial assessments of individuals seeking access to HART Hub services.
• Identify clients' immediate, short-term, and longer-term needs, including health care, mental health and substance use treatment, housing, income, identification, food security, transportation, legal/justice, and other social determinants of health.
• Determine appropriate internal and external service options based on identified client needs, eligibility, and availability.
• Arrange referrals and admissions to medical, treatment, housing, social service, and other identified programs.
• Present potential clients at daily debriefing meetings, case conferences, circles, and/or program application reviews as required.
• Forward assessments and relevant information to appropriate services in accordance with privacy and consent requirements.
• Apply crisis de-escalation techniques, safety planning, and risk assessment protocols as required.
  
  

Client Navigation & Practical Support

• Assist clients in navigating complex health, social service, housing, income, and government systems.
• Provide hands-on assistance with completing applications, obtaining essential documentation, and accessing programs and benefits, including but not limited to:
• Indian Status cards;
• Birth certificates;
• Ontario health cards;
• Ontario Photo Cards, where applicable;
• Ontario Works (OW);
• Ontario Disability Support Program (ODSP);
• Housing applications;
• Long-term care applications and referrals; and
• Other documentation, benefits, and programs required to support client stabilization.
• Maintain working knowledge of Non-Insured Health Benefits (NIHB) programs and other Indigenous-specific services and resources and assist eligible Indigenous clients in accessing available supports.
• Provide clients with clear information regarding available HART Hub housing resources, including current availability and alternative options when HART Hub housing is at capacity.
• Confidently refer clients to appropriate community agencies and service providers.
• Coordinate resources and services across agencies to reduce duplication, gaps, and barriers to care.
• Facilitate warm transfers to internal and external programs and service providers.
• Provide accompaniment to appointments, programs, agencies, or other services when required to support successful engagement and access.
• Advocate on behalf of clients, with their consent, when barriers to accessing appropriate services or supports are identified.
• Participate in case conferences and collaborative service planning to support coordinated client care.
• Provide proactive follow-up and maintain appropriate contact with clients awaiting program admission, housing, treatment, or other services.
• Meet with clients at community or partner service locations when beneficial to support engagement, readiness, and continuity of care.
• Conduct one-on-one meetings with clients and service providers as required.
• Support the safety and care of clients while on duty.
• Provide navigation and connection to programs and services using strengths-based and client-centred approaches.
• Coordinate stepped-care plans and support continuity between levels of care.
  
  

Resource Coordination & System Navigation

• Actively research and remain current on new and existing community resources, services, programs, funding opportunities, eligibility requirements, referral processes, and access pathways.
• Maintain current knowledge of local health, housing, treatment, mental health, substance use, income support, justice, Indigenous, and social service resources.
• Act as a resource to Peer Support, Outreach, and other HART Hub staff who may be unfamiliar with available programs, services, eligibility requirements, or referral pathways.
• Develop and maintain collaborative relationships with community agencies and service providers to facilitate timely client access.
• Identify service gaps and emerging client needs and communicate these to the Program Manager and HART Hub team.
• Support coordinated and collaborative approaches to client care across internal and external service providers.
  
  

Communication & Collaboration

• Work collaboratively on site with Peer Support, Outreach, and other members of the HART Hub interdisciplinary team.
• Maintain strong working relationships with colleagues and community partners across health care, housing, social services, treatment, Indigenous services, and the criminal justice system.
• Foster collaborative relationships with Indigenous and non-Indigenous agencies to support holistic wellness and coordinated service delivery.
• Demonstrate respect, accountability, and cultural humility in all interactions, honouring the values and traditions of the Anishinabek people.
• Participate in staff meetings, team huddles, circles, training, case conferences, and other collaborative planning activities as required.
• Represent SKHC and/or the HART Hub at community events, meetings, outreach initiatives, and partner activities as required.
• Promote harm reduction, anti-oppression, cultural safety, and health equity principles in all client and community interactions.
  
  

Documentation & Data Management

• Maintain accurate, complete, timely, and up-to-date client records, files, applications, letters, referrals, and other written documentation in accordance with program and organizational standards.
• Document relevant client interactions, referrals, follow-up activities, outcomes, and service coordination activities.
• Input required program data, staff activity logs, and client tracking information.
• Ensure all relevant client information is added to the appropriate file or system in a timely manner.
• Maintain records and data in accordance with SKHC privacy, confidentiality, documentation, and information-management policies and applicable legislation.
• Obtain and document appropriate client consent when sharing information or coordinating services with external agencies.
  
  

Professional Development & Compliance

• Maintain and expand knowledge related to harm reduction, pharmacology, substance use and Substance Use Disorders, Motivational Interviewing, trauma-informed care, housing and homelessness, system navigation, and other relevant best practices.
• Maintain knowledge of available Indigenous-specific health and social supports, including NIHB programs and eligibility requirements.
• Participate in relevant training, professional development, team learning, and organizational initiatives.
• Maintain certification and any additional assessment-tool training required by the province, funder, program, or organization.
• Maintain a current Criminal Record Check/CPIC as required.
• Maintain required certifications, including First Aid, CPR, WHMIS, AODA, Health and Safety Awareness Training, NVCI, Mental Health First Aid (MHFA), and Safe Food Handler, as applicable to the position.
• Adhere to all SKHC policies and procedures, including requirements related to health and safety, privacy, confidentiality, professional conduct, and PHIPA.
• Maintain awareness of personal and workplace safety at all times. Assess the circumstances and potential risks associated with each environment and adjust behaviour, approach, and location accordingly to support personal and client safety.
• Perform other duties as assigned by the HART Hub Program Manager and/or CEO.
  
  

Skills And Qualifications

• Social Services Diploma, Bachelor's Degree in Human Services, or a combination of relevant education and equivalent experience.
• Demonstrated experience in client navigation, case management, outreach, social services, housing, mental health and addictions, or a related community-based environment is preferred.
• Strong knowledge of community-based health, housing, income support, treatment, social service, and justice resources.
• Knowledge of Indigenous-specific programs, services, and benefits, including NIHB, is considered a strong asset.
• Knowledge of and experience assisting individuals with government applications, identification documents, housing applications, income supports, and other essential services is an asset.
• Strong understanding of harm reduction, substance use and Substance Use Disorders, including knowledge of commonly used substances and basic pharmacology.
• Knowledge of trauma-informed, culturally safe, strengths-based, and client-centred approaches.
• Demonstrated ability to advocate effectively for clients while supporting client autonomy and self-determination.
• Ability to build relationships and work collaboratively with multidisciplinary teams and external community partners.
• Strong crisis intervention, problem-solving, conflict-resolution, and de-escalation skills.
• Proficiency in Motivational Interviewing and basic counselling/support techniques.
• Strong organizational skills with the ability to coordinate multiple referrals, applications, follow-ups, and client priorities.
• Strong computer skills, including proficiency with Microsoft Office applications and electronic documentation systems.
• Excellent verbal and written communication and interpersonal skills.
• Ability to maintain professional boundaries and exercise sound judgment in complex or rapidly changing situations.
• Demonstrated understanding of privacy, confidentiality, informed consent, and professional documentation requirements.
• Bilingualism in English/French and/or an Indigenous language is considered an asset.
• Familiarity with multidisciplinary service environments, including health, justice, housing, treatment, and community services, is considered an asset.
  
  

Working Conditions

• Full-time, on-site position working Monday to Friday from 8:30 a.m. to 4:30 p.m.
• Regular interaction with individuals who may be experiencing homelessness, substance use, mental health concerns, crisis, or other complex circumstances.
• Work may involve travel or accompaniment to community agencies, appointments, partner organizations, or other service locations.
• The position requires ongoing awareness of personal and client safety and the ability to assess and respond appropriately to changing environments and circumstances.
• The role requires flexibility, sound judgment, professionalism, and the ability to work effectively within a fast-paced, multidisciplinary service environment.