Overview
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.
ETHP is implementing multiple Integrated Care Pathways (ICPs) to improve outcomes for people living with chronic and complex health conditions. Our pathways are grounded in a learning health system approach, equity, and meaningful partner engagement.
In partnership with Michael Garron Hospital, we are launching a new integrated care pathway called VENT+ designed to support individuals and their families recovering after an Intensive Care Unit (ICU) stay who are at a high risk of ventilation and live with multiple co-morbidities.
Position Summary
The Clinical Care Facilitator (Nurse Practitioner) will work as part of an interdisciplinary team to provide advanced clinical care, education, and coordination for patients and families transitioning from ICU to the community as part of the VENT+ integrated care pathway. This rolewill include conducting in-person and virtual follow-ups, developing individualized care plans, and building capacity with patients, families and providers.
The Clinical Care Facilitator (Nurse Practitioner) will play a critical role in bridging inpatient and outpatient care, engaging patients and caregivers during hospitalization, leading individualized recovery goal planning, and supporting continuity of care as patients transition into the community.
Primary Responsibilities
Clinical Care Delivery
- Build therapeutic relationships with patients and families during hospitalization to facilitate smoother transitions post-discharge
- Provide care to patients and families within full Nurse Practitioner scope of practice.
-Conduct initial and ongoing comprehensive assessments (in-person and virtual) for post-ICU patients and families/care partners enrolled in the VENT+ pathway.
- Monitor patient and family progress at regular intervals through scheduled follow-ups.
-Lead and support goals-of-care discussions and advance care planning.
Patient and Family Support
- Serve as the primary point of contact for patients and families.
- Provide education and coaching to patients and families
- Connect patients and families to appropriate services and supports.
Interdisciplinary Collaboration and Coordination
- Work in an NP-MD dyad model and collaborate with allied health professionals (e.g., PT, OT, SW, RPN, RRT, SLP etc.).
- Act as a key liaison between acute care, primarycare, and home/community care providers to promote seamless transitions in care.
- Coordinate care with community partners.
- Participate in team rounding and integrated care planning.
Program Evaluation and Knowledge Translation
- Contribute to a learning health system approach through active participation in evaluation, quality improvement and co-design of the VENT+ pathway.
- Work with clerical, project and research support to streamline documentation, enhance virtual monitoring, and collect outcome data.
EDUCATION
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
- A combination of advanced clinical expertise and strong people skills
- A passion for health equity, innovation, and systems improvement
- A collaborative mindset and the ability to work across disciplines and sectors
- Comfort with ambiguity, complexity, and change
- 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 .