Nurse Practitioner, Clinical Care Facilitator

OVERVIEW

In partnership with Michael Garron Hospital (MGH), the VENT+ Program is an Integrated Care Pathway that supports individuals and family/caregivers recovering from an Intensive Care Unit (ICU) stay, with a particular focus on patients with multiple comorbidities and complex care needs..
MGH is a recognized leader in prolonged ventilation and the care of patients recovering from critical illness, with significant clinical expertise in supporting recovery, transitions in care, and quality of life. The NP will have the opportunity to work alongside experienced clinicians and thought leaders in this area and contribute to an innovative model of integrated care.

The VENT+ pathway addresses an important gap in care for patients recovering from critical illness. Patients typically have complex medical needs, moderate to high frailty, and functional, cognitive, or social changes following an ICU stay, often requiring caregiver support and coordination across multiple providers and care settings.

VENT+ uses an interdisciplinary, whole-person approach, bringing together occupational therapy, physiotherapy, social work, psychiatry, respiratory care, and other clinical expertise. The team supports patients and caregivers while giving providers a collaborative forum to problem-solve, share expertise and navigate care needs.

The program aims to improve patient and caregiver experience, recovery and quality of life, care coordination, avoidable acute-care utilization, and provider experience and satisfaction.

Position Summary
The Nurse Practitioner, Clinical Care Facilitator is a core member of the VENT+ interdisciplinary team, providing advanced clinical care and case management for patients transitioning from ICU to the community.
Working closely with the interdisciplinary team, including OT, PT and Social Work, the Nurse Practitioner leads comprehensive assessments, develops individualized care and recovery plans, and coordinates care across hospital, primary care, specialist and community settings. Over the approximately 18-month pathway, the Nurse Practitioner works in partnership with patients and caregivers to monitor progress, address evolving needs, and support patients in achieving their individual recovery goals. The role also works closely with primary care providers and other members of the care team to support safe transitions, strengthen continuity of care, and optimize recovery and quality of life.

PRIMARY RESPONSIBILITIES
Clinical Care Delivery
• Provide care within full Nurse Practitioner scope of practice, including assessment, diagnosis, prescribing, and management of complex post-ICU conditions
• Build therapeutic relationships with patients and families during hospitalization to support smoother transitions post-discharge
• Conduct comprehensive initial and ongoing assessments (in-person and virtual), including risk stratification and identification of care needs
• Monitor patient progress through regular follow-ups, including early identification of deterioration and escalation as required
• Develop individualized care plans and SMART recovery goals in partnership with patients and caregivers
• Lead goals-of-care discussions and advance care planning conversations
• Apply geriatric lens to care, including assessment of falls risk, mobility, cognition, mood, polypharmacy, and frailty
Patient and Family Support
• Serve as a primary point of contact for patients and families throughout the care journey
• Provide education, coaching, and support to promote self-management and recovery
• Support caregivers in navigating complex care needs and system challenges
• Connect patients and families to appropriate health and social services
Interdisciplinary Collaboration and Coordination
• Work within an NP-MD dyad model and collaborate closely with allied health professionals (e.g., NP, PT, OT, SW, RPN, RRT, SLP)
• Be included into MGH NP Community of Practice
• Act as a key liaison across acute care, primary care, and home/community care to ensure seamless transitions
• Proactively identify gaps in care and mobilize appropriate resources across sectors
• Coordinate care with community partners, including rehabilitation services and Ontario Health@Home
• Participate in interdisciplinary rounds and integrated care planning
Program Evaluation and Knowledge Translation
• Actively contribute to a learning health system approach, including quality improvement and pathway co-design
• Support data collection, documentation, and use of tools (e.g., REDCap, virtual monitoring platforms)
• Identify opportunities for improvement and support translation of insights into practice changes
• Work with clerical, project and research support to streamline documentation, enhance virtual monitoring, and collect outcome data.

SALARY

The salary range for this role is $61.9614 to $72.8957/hour.

EDUCATION

• Required: 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

QUALIFICATIONS

• Clinical Expertise: Minimum 3 years clinical experience in critical care, respiratory care, or complex chronic disease management.
• Collaboration: Demonstrated experience working in interdisciplinary and cross-sectoral teams to facilitate care transitions.
• Interpersonal Skills: Strong empathy and active listening skills to support people-centered care

What You Bring

• Advanced clinical expertise combined with strong relational and communication skills
• Comfort working in ambiguity and navigating complex, evolving care environments
• Ability to manage competing priorities and make sound clinical decisions in resource-constrained settings
• A collaborative mindset and ability to work across disciplines and organizations
• A passion for health equity, integrated care, and system improvement
- 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 .

About East Toronto Health Partners
East Toronto Health Partners (ETHP) is the Ontario Health Team serving East Toronto. We are a network of over 100 health, community, and social service organizations, working alongside patients, caregivers, and community advisors to build a more connected and equitable health system.
Our work focuses on making care easier to access, improving transitions between care settings, and supporting people to live well in their communities.
As part of this work, ETHP is implementing Integrated Care Pathways (ICPs) for patients with chronic and complex conditions, grounded in a learning health system approach, equity, and strong cross-sector collaboration.

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.