HOOPP: Effective April 25, 2026, the CFHT is a participating employer of the Healthcare Ontario
Pension Plan (“HOOPP”).

Position: Permanent Full-Time (1.0 FTE) Registered Nurse – Geriatric Outreach Team
Reports To: Program Manager

Position Summary:
As a key member of the Couchiching Family Health Team (CFHT), and an integral part of an
interdisciplinary health care team, you will deliver nursing care in accordance with FHT policies
and professional practice standards.

The Geriatric Nurse is a specialist in geriatric care and is responsible for the planning,
coordination and delivery of services to patients who are seniors and their families and
caregivers. Working in collaboration with an interdisciplinary team, the Geriatric Nurse will share
expertise and knowledge of health promotion and disease prevention, helping to connect patients
with appropriate services and professionals. The RN will apply an anti-oppressive lens in
supporting diverse older adults, including those facing systemic barriers.

Why Join Us:
Join a collaborative, team-based primary care environment focused on improving access and
continuity of care in the
community, and be part of a progressive organization advancing Ontario Health’s Primary Care for
All initiative.

Roles and Responsibilities: Assessment:

• Screen, prioritize and process client referrals to the designated program
• Review client clinical information obtained through the physician or IHP referral, laboratory
  results and health records
• Conduct consultations with clients/family to obtain relevant information and assess
  client/family learning’s and needs
• Conduct home visits
• Complete Comprehensive Geriatric Assessments (CGA’s)
• Complete Coordinated Care Plans for clients in the program
  Planning:
• In collaboration with the Family Physician and other members of the interdisciplinary team,
  develop and discuss appropriate individualized care plan with the client/family/caregiver based on
  best practices
• Partner with community resources in developing goals and objectives and help guide the family
  and client to the necessary services available
• Provide ongoing case management for patients identified as at risk and enrolled in the geriatric
  program
• Collaborate with the Geriatrician to deliver effective primary care
• Recommend and teach client’s treatment protocols and education as required
• Document all health notes into the EMR daily and arrange necessary follow up
  Reporting:
• The Geriatric RN will report directly to the Team Lead/Manager
• Prepare monthly statistical reports to be submitted to Ontario Health as needed
  Team Development:
• Proven ability to work collaboratively within an interprofessional team, fostering strong
  working relationships across the FHT, multidisciplinary team members, and physician office teams
• Promote awareness of the FHT’s program and services
• Actively participate in staff, team, and committee meetings, if appropriate
• Participate in the development, planning and evaluation of treatment, education, counselling,
  and health promotion activities of the FHT

Professional Development:

• Maintain and develop professional competence through ongoing professional development
• Fully participate in the Quality Assurance Program of the College of Nurses of Ontario
• Stay current and aware of opportunities to implement new, evidenced based methods of client
  assessment, treatment, and programming
• Participate in clinical projects as required
  Organizational Nursing Support:
• Adapt to the staffing needs of the CFHT by assisting with Nursing responsibilities in other CFHT
  programs and services as required

Skills/Knowledge Requirements:

• Superior leadership, organization, evaluation, time management, communication, and interpersonal
  skills
• Demonstrated knowledge of culturally responsive care, ability to work across difference and
  experience, supporting equity-deserving older adults
• Experience and/or background in mental health, is considered an asset
• Proficiency in the use of computer hardware and software, particularly in Microsoft word, excel,
  outlook and electronic medical records
• Works in compliance with Health and Safety laws adhering to safe work practices and procedures
  established by the CFHT
• Excellent verbal and written communication
• Demonstrated ability to work well autonomously
• Adaptable to change
• Knowledge in current, evidence-based methods and practice of primary care delivery
• Excellent oral/written/interpersonal skills
• Other duties as required

Education/Specific Job Requirements:

• Baccalaureate of Science in Nursing required
• Current registration with the CNO
• Mandatory Declaration of Professional Liability Protection upon hire, and annually
  thereafter
• Gerontological Nursing Certification preferred
• Current membership with the RNAO preferred
• Basic CPR
• Current Ontario Driver’s License and access to reliable vehicle for travel to various
  communities
• Provide evidence of a clean driver abstract and proof of insurance
• Able to work flexible hours including evenings if required
• Police Record/Vulnerable Record Check
• It is a condition of employment that you receive the necessary vaccinations to protect against
  infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental
  and public health authorities from time to time
  Experience:
• Minimum 3-5 years experience in a community and/or Primary Health Care setting with a focus on
  geriatric care
• Relevant community-based or lived experience working with older adults may be considered as an
  asset

The Couchiching Family Health Team supports diversity, equity and a workplace free from harassment
and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection
process and workplace. If you are contacted to participate in our recruitment process, please
advise the interview coordinator of any accommodations. The CFHT has an Accommodation Policy and
Procedure to ensure you have access to a fair and equitable process. While we thank all applicants,
only those contacted for an interview will be acknowledged.

Please submit cover letter and resume including position title in subject line to: careers@cfht.ca