Clinical Care Facilitator, Physician Assistant/Nurse Practitioner

A. BACKGROUND

East Toronto Health Partners (ETHP) is the Ontario Health Team (OHT) serving East Toronto. We are a network of over 100 health, community, and social service organizations, alongside patients, caregivers, and community advisors, working together to create a more integrated and equitable health system. Our goal is to make it easier for people to access care, navigate the system, and thrive in their communities.
In partnership with Michael Garron Hospital, ETHP is implementing multiple Integrated Care Pathways (ICPs) to improve outcomes for people living with chronic and complex health conditions, such as COPD, Heart Failure, post ICU recovery, and Community-Acquired Pneumonia. Our pathways are grounded in a learning health system approach and bring together hospital, primary care, home care and community providers to support transitions, strengthen patient and caregiver confidence, and reduce avoidable emergency department visits and readmissions.

B. POSITION SUMMARY

We are looking for a Physician Assistant or Nurse Practitioner to join our team as a Clinical Care Facilitator (CCF). The CCF is a core member of the interdisciplinary team and the primary point of contact for enrolled patients during their transition from hospital to home.
The CCF conducts assessments within their professional scope, develops individualized recovery plans, provides evidence-informed education and structured clinical follow-up, coordinates care with MGH2Home, primary care, physicians and community partners. Working in partnership with patients and caregivers, the CCF monitors recovery, addresses barriers and supports progress toward recovery.

PRIMARY RESPONSIBILITIES

Clinical Assessment and Recovery Support
• Review referrals, confirm eligibility, assess clinical risk factors, and enroll patients before discharge
• Conduct assessments within professional scope and develop individualized recovery plans and achievable goals with patients and caregivers.
• Provide structured follow-up, monitor recovery progress, identify deterioration or barriers to recovery, and initiate appropriate escalation or transition to ongoing care.
• Support symptom management, functional recovery, and patient confidence in safely recovering at home.
• Provide clinical interventions within authorized scope and seek appropriate medical or interdisciplinary input for needs requiring additional expertise.
• Support transition to primary care, community services or another EastTCaN pathway when ongoing needs are identified.
Patient and Caregiver Education
• Build therapeutic relationships with patients and caregivers that support engagement, confidence, and recovery at home.
• Provide evidence-informed education on pneumonia recovery, medications, symptom monitoring, warning signs, and when to seek help.
• Use teach-back and coaching techniques to strengthen understanding, support self-management, and confirm readiness to manage recovery at home.
• Address language, accessibility, technology, and social barriers that may affect recovery and access to care.
Care Coordination and MGH2Home Collaboration
• Serve as the primary point of contact for enrolled patients during the transition from hospital to home.
• Coordinate care with MGH2Home, primary care, physicians, home care, and community partners to support a seamless recovery experience.
• Facilitate referrals, communication, and access to services that address ongoing clinical, functional, and social needs.
Interdisciplinary Practice and Clinical Escalation
• Work collaboratively with physicians, NP/PA colleagues, and interdisciplinary providers to support patient recovery and continuity of care.
• Apply established escalation pathways, communicate clinical concerns promptly, and arrange urgent assessment when required.
• Participate in care planning, case reviews, and documentation to support safe, coordinated, patient-centred care.
Program Development and Evaluation
• Apply evidence-informed practice and clinical guidelines to support pathway delivery and patient outcomes.
• Contribute to the development and refinement of pathway tools, educational resources, workflows, and communication processes.
• Support evaluation and continuous improvement efforts to enhance patient experience, care transitions, and reduce avoidable emergency department visits and readmissions.
• This position is open to a Nurse Practitioner, Physician Assistant. Clinical responsibilities will be aligned with the successful candidate’s professional scope, demonstrated competencies and organizational policies, including applicable orders, medical directives and physician supervision or delegation arrangements. The role includes access to designated medical support and clear escalation processes.

EDUCATION

• Nurse Practitioner: Current registration as a Nurse Practitioner (RN-EC) in good standing with the College of Nurses of Ontario (CNO), with Adult or Primary Health Care specialty.
• Physician Assistant: Current registration in good standing with the College of Physicians and Surgeons of Ontario as a Physician Assistant.

EXPERIENCE

• Minimum 2 years of clinical experience in respiratory, acute, community, chronic disease, or older adult care.
• Strong assessment, clinical judgment, and escalation skills, including recognition of patient deterioration.
• Experience supporting hospital-to-home transitions, care coordination, and interdisciplinary collaboration.
• Strong patient and caregiver education skills, including teach-back and self-management support.
• Excellent communication, documentation, and organizational skills
• Knowledge and experience with EMRs, community resources, quality improvement, or service implementation are assets.
- All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN)
[formerly Toronto East General Hospital (TEGH)] agree to work within the legislated practices of the
Occupational Health and Safety Act of Ontario

- All employees of MGH are responsible to contribute to a transparent culture of patient and staff safety by adhering to and a biding by patient and staff safety policies and procedures set by MGH

- All employees are accountable for protecting the psychological health and safety of themselves and their co-workers through adherence to MGH's policies and practices.

What You Bring
• A commitment to person-centred care, health equity and recovery at home.
• Sound professional judgment and an understanding of when to seek additional expertise.
• A collaborative approach to working with patients, caregivers and partners across organizations.
• Flexibility and initiative to help develop and improve a new integrated care pathway.

EMPLOYMENT EQUITY & ACCESSIBILITY STATEMENT

Michael Garron Hospital (MGH) champions accessibility, diversity and equal opportunity through the creation of an inclusive and diverse work environment. At Michael Garron Hospital, we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialized and LGBTQ2S+ communities, people of colour, women, people with disabilities and individuals who identify with the diverse communities that we serve, to join the MGH team.

Through our values of Compassion, Respect, Integrity, Inclusion and Courage, Michael Garron Hospital is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and Ontario Human Rights Code (OHRC). Should you require an accommodation at any stage of the recruitment process, please let us know how we can work with you to meet your needs.

This job posting is a confirmed, active vacancy for which we are currently seeking a qualified candidate.

MGH is committed to leveraging new technologies and working efficiently. As a result, artificial intelligence systems may be used as part of our process to screen, assess, and or select applicants for this position.