Overview About East Toronto Health Partners (ETHP) is the Ontario Health Team serving East Toronto. We are a network of over 100 health, community, and social service organizations, working alongside patients, caregivers, and community advisors to build a more connected and equitable health system. Our work focuses on making care easier to access, improving transitions between care settings, and supporting people to live well in their communities. As part of this work, ETHP is implementing Integrated Care Pathways (ICPs) for patients with chronic and complex conditions, grounded in a learning health system approach, equity, and strong cross‑sector collaboration.
About the VENT+ Pathway In partnership with Michael Garron Hospital, the VENT+ Integrated Care Pathway supports individuals and family/caregivers recovering from an Intensive Care Unit (ICU) stay, who are at high risk of prolonged ventilation and live with multiple co‑morbidities. Patients in this pathway are typically adults with moderate to high frailty, complex medical needs, and functional or cognitive changes following critical illness. Many require significant caregiver support and coordination across multiple providers and care settings.
Position Summary The Clinical Care Facilitator (Nurse Practitioner) is a core member of the VENT+ interdisciplinary team, providing advanced clinical care and coordination for patients transitioning from the ICU to the community. This role focuses on supporting high‑risk patients with complex recovery needs, bridging care across acute, primary and community settings. The Clinical Care Facilitator will lead comprehensive assessments, develop individualized recovery plans, and work closely with patients, caregivers and providers to support protected, coordinated and person‑centered care. This role requires strong clinical judgment, comfort with complexity, and the ability to navigate fragmented systems while supporting patients and families through uncertain recovery trajectories.
Key Responsibilities Clinical Care Delivery Provide care within full Nurse Practitioner scope of practice, including assessment, diagnosis, prescribing and management of complex post‑ICU conditions




Build therapeutic relationships with patients and families during hospitalization to support smoother transitions post‑discharge
Conduct comprehensive initial and ongoing assessments (in‑person and virtual), including risk stratification and identification of care needs
Monitor patient progress through regular follow‑ups, including early identification of deterioration and escalation as required
Develop individualized care plans and SMART recovery goals in partnership with patients and caregivers
Lead goals‑of‑care discussions and advance care planning conversations
Apply a geriatric lens to care, including assessment of falls risk, mobility, cognition, mood, polypharmacy and frailty
Patient and Family Support Serve as a primary point of contact for patients and families throughout the care journey
Provide education, coaching and support to promote self‑management and recovery
Support caregivers in navigating complex care needs and system challenges
Connect patients and families to appropriate health and social services
Interdisciplinary Collaboration and Coordination Work within an NP‑MD dyad model and collaborate closely with allied health professionals (PT, OT, SW, RPN, RRT, SLP)
Act as a key liaison across acute care, primary care and home/community care to ensure seamless transitions
Proactively identify gaps in care and mobilize appropriate resources across sectors
Coordinate care with community partners, including rehabilitation services and Ontario Health@Home
Participate in interdisciplinary rounds and integrated care planning
Program Evaluation and Knowledge Translation Actively contribute to a learning health system approach, including quality improvement and pathway co‑design
Support data collection, documentation and use of tools (REDCap, virtual monitoring platforms)
Identify opportunities for improvement and support translation of insights into practice changes
Work with clerical,



project and research support to streamline documentation, enhance virtual monitoring and collect outcome data
Education Required: Current registration as a Nurse Practitioner (RN‑EC) in good standing with the College of Nurses of Ontario (CNO), with Adult or Primary Health Care specialty
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‑centred care
What You Bring Advanced clinical expertise combined with strong relational and communication skills
Comfort working in ambiguity and navigating complex, evolving care environments
Ability to manage competing priorities and make sound clinical decisions in resource‑constrained settings
A collaborative mindset and ability to work across disciplines and organisations
A passion for health equity, integrated care and system improvement
All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN) are required to work within the legislated practices of the Occupational Health and Safety Act of Ontario
EMPLOYMENT EQUITY & ACCESSIBILITY STATEMENT Michael Garron Hospital (MGH) champions accessibility, diversity and equal opportunity through the creation of an inclusive and diverse work environment. At MGH we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialised and LGBTQ2S+ communities, people of colour, women, people with disabilities and individuals who identify with the diverse communities that we serve, to join the MGH team. Through our values of Compassion, Respect, Integrity, Inclusion and Courage, MGH is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and Ontario Human Rights Code (OHRC). Should you require an accommodation at any stage of the recruitment process, please let us know how we can work with you to meet your needs.

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📌 Nurse Practitioner, Clinical Care Facilitator (Ontario)
🏢 Michael Garron Hospital
📍 Ontario