Nurse Practitioner – The Centre for Family Medicine FHT (Kitchener)

The Centre for Family Medicine FHT is currently seeking a
(Registered Nurse, Extended Class)

to join the KW4 Community Ward Team for four days per week

The KW4 Community Ward-In Home Team (CWT) is a partnership between the Centre for Family Medicine and the Waterloo-Wellington Local Health Integration Network. CWT is an inter-professional team that coordinates and provides in-home primary care to complex, high users of the health care system in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including patients who:

  • have complex chronic conditions
  • are living with mental health, psychosocial and/or addictions challenges
  • are very frail or have frequent falls
  • are not managing well, or are not getting the care and support they need
  • are visiting the ER or being hospitalized frequently, and/or
  • are unable to attend regular healthcare appointments

Our team consists of full-time LHIN care coordinators, an outreach worker and team assistant, and part-time nurse practitioners, a chiropractor/mobility specialist, a pharmacist, an occupational therapist and a physician consultant.

Position Overview

The Nurse Practitioner is a new position that has been created to increase the capacity of CWT through the establishment and staffing of a Community Ward Clinic. Reporting to the Manager of KW4 and Health Links Projects, the Nurse Practitioner will liaise with the in-home team, and in partnership with a new Social Worker, offer scheduled and drop-in primary care appointments for Community Ward patients who do not require in-home care.  This position will provide direct acute and chronic care for patients both in the home and in clinic, with a strong emphasis on social determinants of health. This role will liaise with a wide variety of stakeholders, and will evolve over time as the CW Clinic model is further developed.

Additional Responsibilities

Team Participation

  • Works in partnership with the Manager, a new Social Worker and the KW4 Community Ward Team to develop and implement a clinic to support Community Ward patients
  • Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team meetings
  • Ensures that the Team and other stakeholders are kept informed about clinic developments and new and existing patient challenges as necessary
  • Consults with other team members who have different or enhanced areas of expertise

Patient Care

  • Listens to patients to identify their social, physical and emotional needs
  • Builds on existing resources and connects patients to additional resources to create a support network
  • Advocates for services as necessary
  • Negotiates with other care providers about how service is provided to ensure patient participation in their own care
  • Follows all safety protocols while working with residents in their home/community and clinic

Documentation and Records Management

  • Participates in the development of coordinated care plans (CCPs)
  • Documents and maintains clear records in an EMR of each patient visit including supports, services and gaps
  • Provides clear and timely communication with other healthcare and social service providers
  • Other correspondence as required

Qualifications and Experience:

  • Current CNO Certificate as RN (EC)
  • Demonstrated ability to work independently within the RN (EC) scope of practice
  • Preferred experience or education in primary health care and an adult specialty
  • Demonstrated ability to work collaboratively with other Allied Health Professionals
  • Demonstrated excellence in clinical judgment, health assessment and therapeutic skills
  • Demonstrated experience in social determinants of health
  • Proven relationship building and problem-solving skills
  • Proven ability to keep confidential information regarding patients, health care providers, employees, business operations and team information
  • Demonstrated ability to listen effectively and to build working relationships with patients, and other team members
  • Computer knowledge of email, voicemail as well as computer literacy
  • Access to a reliable vehicle and a valid Ontario driver’s license are required
  • ER experience and/or certification in mental health, addictions, and/or counselling are all assets

At the Centre for Family Medicine we strive to offer an exciting and caring work environment. If this position is of interest to you please send your letter of interest and your Curricula Vitae to:

Ms. Trish O’Toole, Project Coordinator

The Centre for Family Medicine Family Health Team

The Centre for Family Medicine Family Health team is a respectful and inclusive workplace. Upon individual request, hiring processes will be modified to remove barriers to accommodate those with disabilities.  Should any applicant require accommodation through the application, interview or selection processes, please contact Human Resources at for assistance.