SAFHT - REGISTERED NURSE CARE MANAGER

Registered NURSE CARE MANAGER

• Position Title: Registered Nurse Care Manager 
  Hours: Full Time (Days, Evenings, Weekends)
• Location: Aurora with travel across York Region & South Simcoe
• Job Type: Permanent full time with Healthcare of Ontario Pension Plan (HOOPP)

About Us
Join our dynamic Inter-professional Primary Care Team (IPCT) dedicated to providing patient-centered, population health-focused care. Our mission is to address medical and social determinants of health, with a strong emphasis on equitable access for diverse and equity-deserving populations, including vulnerable groups. We deliver care through in-person, virtual, and mobile services and emphasize Indigenous and trauma-informed practices.

Our Aurora clinic serves as the primary workplace, with occasional travel required within the Northern York Region South Simcoe Ontario Health Team (NYSS-OHT) region and training opportunities at our Southlake Academic Family Health Team (FHT) site in Newmarket.

About the Role

The Registered Nurse (RN) is responsible for coordinating and delivering comprehensive care to patients with chronic conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and other related illnesses. The RN will work closely with the Primary Care Provider (PCP), patients, their families, and the Interprofessional Primary Care Team (IPCT) to manage, monitor, and optimize the care of these patients, ensuring a high quality of life and preventing complications.

Key Responsibilities

• Conduct regular and thorough health assessments for patients with chronic diseases, monitoring key indicators such as blood pressure, glucose levels, and other relevant metrics.
• Ensure adherence to prescribed medication regimens by educating patients on the importance of compliance, potential side effects, and appropriate actions for missed doses.
• Track symptoms and health status to identify early signs of deterioration or complications, taking proactive steps to prevent hospitalizations or worsening of the condition.
• Collaborate with Primary Care Provider (PCP) and other members of the IPCT to develop a care plan and adjust the plan based on patient progress and emerging health needs.
• Provide education and support to patients and their families, empowering them with the knowledge and tools necessary for effective self-management of their chronic conditions.
• Coordinate referrals and communication with specialists, integrating their recommendations into the overall care plan to ensure comprehensive and continuous care.
• Maintain a comprehensive understanding of available external programs and resources to ensure that patients are appropriately referred to these programs to enhance their care, providing additional support and resources beyond the IPCT clinic.
• Facilitate and support smooth transitions of care for patients moving between different levels of care, such as from hospital to home or from primary care to specialist services. Ensure that all aspects of the patient's health and well-being are addressed during these transitions.
• Serve as the first point of contact for the designated patient population, providing rapid access and response to their needs. This includes managing urgent concerns, coordinating timely interventions, and ensuring that patients receive prompt and effective care, particularly for those identified as high-risk or with complex chronic conditions.
• Maintain accurate and comprehensive documentation in the EMR system.

Qualifications

• Bachelor of Science in Nursing (BScN) from an accredited institution; additional certification in chronic disease management, case management, or a related field is preferred.
• Active registration and good standing with the College of Nurses of Ontario (CNO); and proof of professional liability insurance.
• Proficient in using electronic medical records (EMR) systems and other healthcare technology commonly used in Ontario’s primary care settings.
• Strong knowledge of primary care practices, integrated care models, and multidisciplinary team coordination.
• Excellent interpersonal, written and oral communication skills.
• Understanding of and sensitivity to the diverse cultural, social, and economic backgrounds of Ontario's patient population, ensuring equitable and accessible care.
• Commitment to ongoing professional development and staying current with best practices in chronic disease management and care coordination.
• Demonstrated experience in Community and/or Primary care preferred
• Valid driver’s license, regular access to a vehicle and appropriate insurance for personal automobile