The Centre for Family Medicine
Term (Duration): 
The KW4 Community Ward-In Home (CWT) is an inter-professional team that delivers in-home primary care to complex patients in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including those 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
- cannot get to regular office appointments for whatever reason

Our team currently consists of part-time nurse practitioners, two outreach workers, a social worker, a chiropractor/mobility specialist, a pharmacist, a consulting physician, and a team-assistant. While the team is primarily an in-home team, it operates a supporting clinic, limited in scope, for a sub-set of its patients. In addition, it works collaboratively with other community partners including supporting clinics operating in several community locations.

Position Overview
The RN is a key clinical position on the team whose role is to provide acute and chronic care for patients in their homes with a strong emphasis on social determinants of health. The RN takes a leadership role in triaging patients, and requires initiative and passion in caring for our population. The role and responsibilities of the position will evolve and develop over time, along with the Team.

Additional Responsibilities
Team Participation
- Works as both a lead and support to other Team members (including Nurse Practitioners) working with
specific patients
- Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team
- Ensures that the Team and other stakeholders are kept informed about clinical developments and new
and existing patient challenges as necessary
- Consults with other Team members who have different or enhanced areas of expertise
Works with patients through a primary, secondary and tertiary prevention model
- Listens to patients to identify their social, physical and emotional needs in order to develop patientspecific
- 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 (OSCAR) 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
- Demonstrated ability to work independently within the RN scope of practice
- 3 years of experience in healthcare, preferably working with complex patients
- Preferred experience or education in primary health care and an adult specialty
- Ability to triage, strong med-surgical skills, and excellence in at least one chronic disease (example: diabetes or COPD)
- 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
- Access to a reliable vehicle and a valid Ontario driver's license are required
- Experience and/or certification in mental health, geriatrics, addictions, and/or counselling are all assets
Date Posted: 
Fri, Apr 5 2019
Job Location: 
How to Apply: 
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 by Monday April 22nd to:
Human Resources, The Centre for Family Medicine FHT

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
Mon, Apr 22 2019
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