Job Title:
Lead Physician- Population Health Clinic

Employmentterms:
Part time / Full-Time (0.5-1.0 FTE) – 17.5 - 35 hours/week, with flexibility for clinic needs and possible evening/weekend work

Salary range:
$182.40 per hour along with extended health benefits and HOOPP pension plan based on eligibility

Expected start date:
ASAP

Number of positions:
1

Reporting to:
Medical Director,FlemingdonHealth Centre (FHC)

Locations:
Population Health Clinic and partner sites

Application deadline:
Open until filled

Vacancy Status:
New Position

Unionized Position:
Non-union

Background:
About this posting
This is an opportunity to help launch a recent, community-connected model of primary care from the ground up.As part of a broader effort to expandequitableaccess to team-based primary care, the clinic will connect residents to comprehensive health services and support Ontario's goals for primary care attachment.Thesuccessfulcandidatewill join a growing interdisciplinary team and contribute to a clinic designed to improve access, support primary care attachment, and make a meaningful impact for residents, especially newcomers and others who have traditionally faced barriers to navigating the health system.

About the Population Health Clinic
The Population Health Clinic is aneighborhood-based, interdisciplinary primary care model that brings health and community services together in one accessible location. Developed through a partnership of Community HealthCentres, includingFlemingdonHealth Centre, Access Alliance, and South Riverdale Community Health Centre, the clinic is co-located within New Circles,a registered charity that provides free clothing, settlement support, employment training, and community connections to individuals and families facing barriers. This is designedtocreate a low-barrier pathway into the health system andbuild ontrusted relationships alreadyestablishedwithin the community.

Through a team-oriented team of physicians, nurse practitioners, registered nurses, allied health professionals, and administrative staff, the clinic will provide integrated, person-centredcare that improves access to primary care, advances health equity, and supports better health outcomes for the communities it serves. This is an opportunity to be part of an innovative model of community-connected care that is helping shape the future of primary health care in East Toronto.

Position Summary
The Lead Physician will provide clinical and systems leadership for the Population Health Clinic while also delivering comprehensive primary care as part of its interdisciplinary team. The Lead Physician will assess, diagnose, treat, and manage acute, episodic, and chronic medical conditions; provide preventive care and health promotion; support patient attachment and continuity; and coordinate care with internal and external providers.

The Lead Physician will help translate the clinic’s population health vision into an effective, equitable, and sustainable model of care. Working with FHC leaders, participating Community Health Centres, New Circles, community partners, patients, and residents, the Lead Physician will guide service and pathway design, support implementation, strengthen clinical integration, and use data and lived experience to improve access and outcomes. In this partnership-based clinic model, the Lead Physician will also support staff performance management, recognizing that some roles (ie. Nurse Practitioners, Registered Nurses, Social Workers, System Navigators, Medical Secretaries, health promoters, operational leaders, partner organizations, and community services) may be employed by different participating organizations.

Responsibilities include
Direct Clinical Care

Provide comprehensive, client-centred primary care services, including assessment, diagnosis, treatment, and follow-up.

Manage acute, episodic, and chronic medical conditions commonly seen in primary care settings.

Order, interpret, and act upon diagnostic testing, investigations, and specialist reports as appropriate.

Prescribe medications and therapies consistent with professional standards, evidence-informed practice, and client needs.

Provide preventative care, screening immunizations,



sexual and reproductive health care, chronic disease management, mental health care, and health promotion services within scope.

Support continuity of care and patient attachment within the Population Health Clinic model.

Provide care to clients with complex medical, psychosocial, mental health, substance use, and social needs.

Apply crisis de-escalation, supportive guidance, and system navigation approaches when needed to keep clients connected to care.

Ensure standards of client care are maintained according to recognized clinical guidelines, applicable legislation, and organizational policies.

Maintain timely, accurate, and complete clinical documentation in the EMR or other required systems.

Care Coordination and Collaboration

Work collaboratively with the interdisciplinary team to support integrated care planning, continuity of care, and client attachment.

Participate in team huddles, case conferences, interprofessional case reviews, and care planning meetings.

Make referrals to specialists, hospitals, community agencies, internal services, and partner organizations as appropriate.

Support transitions between services and help ensure clients remain connected to the most appropriate care and supports.

Provide clinical consultation and guidance to other members of the interdisciplinary team as appropriate.

Collaborate with partner organizations and community providers to support coordinated, equitable, and stigma-free care.

Contribute to the development and refinement of referral, intake, documentation, follow-up, and care coordination workflows.

Comply with all privacy, confidentiality, and health information requirements.

Health Promotion, Equity and Population Health

Integrate health promotion principles into clinical care using a determinants-of-health approach.

Provide accessible health education to clients, families, and groups regarding health conditions, treatment options, prevention, lifestyle, nutrition, and available community resources.

Provide culturally responsive, trauma-informed, anti-oppressive, and equity-focused care.

Support access to care for newcomers, unattached patients, and clients facing social, structural, or systemic barriers.

Identify opportunities to improve access, attachment, prevention, and health outcomes through a population health approach.

Participate in outreach and community engagement activities where appropriate.

Advocate for equitable access to health care and support service approaches that reduce barriers for priority populations.

Clinical Leadership, Systems Design, Partnership and Engagement

In collaboration with the Medical Director, provide clinical leadership for the design, implementation, evaluation, and ongoing evolution, including performance management of clinical team within the Population Health Clinic, in alignment with FHC's strategic priorities and the shared objectives of clinic partners.

Apply systems thinking and human-centred design methods to understand patient and provider journeys, identify service gaps and bottlenecks, and co-design practical solutions that improve access, attachment, continuity, equity, and integration.

Translate strategic goals and community needs into clear clinical pathways, service standards, workflows, roles, escalation processes, and shared accountabilities that can be implemented across organizational boundaries.

Convene and facilitate collaborative planning with FHC teams, partner Community Health Centres, New Circles, hospitals, primary care providers, community agencies, and other health-system partners.

Build and sustain trusted relationships with patients, residents, community leaders, and equity-deserving communities; ensure engagement is accessible, culturally responsive, trauma-informed, and meaningfully influences service design and improvement.

Support the development of partnership structures,



including shared objectives, decision-making processes, communication mechanisms, and approaches to resolving operational or clinical issues.

Represent the Population Health Clinic at relevant internal and external planning tables, committees, and community forums, as delegated by the FHC Medical Director, and communicate emerging opportunities, risks, and dependencies.

Use quantitative data, qualitative feedback, implementation experience, and community knowledge to establish priorities, test changes, assess impact, and recommend adaptations to the model of care.

Champion change management and implementation activities, including stakeholder readiness, communication, training, adoption, and sustainability planning.

Identify and elevate clinical, operational, partnership, equity, and system-level risks to the FHC Medical Director and appropriate partner leadership, and contribute to timely mitigation strategies.

Program Development and Quality Improvement

Contribute to the development of clinic workflows, standard operating procedures, referral pathways, and care coordination tools.

Participate in quality improvement, reporting, evaluation, and data collection activities as required.

Support the identification of service gaps, access barriers, and opportunities to improve client-centred care.

Contribute to policy and process development related to clinical care, documentation, privacy, interdisciplinary collaboration, and access.

Lead, in collaboration with FHC and clinic partners, the implementation and ongoing development of the Population Health Clinic model.

Support student placements, learner experiences, teaching, mentorship, or clinical orientation activities as appropriate.

Participate in and, where appropriate, facilitate clinic planning discussions related to service delivery, operational effectiveness, clinical quality, resource use, and sustainability.

Perform other related duties as required to support the functioning of the Population Health Clinic.

Skills and Qualifications
Required Qualifications

Current independent licensure in good standing with the College of Physicians and Surgeons of Ontario.

Certification from the College of Family Physicians of Canada or equivalent family medicine training and experience.

Experience providing comprehensive primary care services.

Thorough, current medical knowledge andproficiencyin conducting comprehensive health histories, physical assessments, diagnostic assessment, and care planning.

Experience assessing and managing acute, episodic, and chronic medical conditions.

Strong clinical judgement, diagnostic, treatment, prescribing, and care planning skills.

Excellent communication, documentation, organization, and collaboration skills.

Demonstrated ability to work effectively in an interdisciplinary team environment.

Demonstrated clinical leadership and ability to guide interdisciplinary work through collaboration, facilitation, influence, and shared decision-making.

Demonstratedsystemsthinking, with the ability to connect population needs, patient experience, clinical practice, operations, partnerships, and health-system priorities.

Experience building relationships and engaging meaningfully with organizational partners, community agencies, patients, residents, or equity-deserving communities.

Commitment to anti-racism, anti-oppression, equity, accessibility, and culturally responsive care.

Preferred Qualifications

Experience working in a Community Health Centre or community-based primary care setting.

Experience working with newcomers, unattached patients, equity-deserving communities, and clients with complex health and social needs.

Experience with mental health, substance use, trauma-informed care, harm reduction, or complex care coordination is considered an asset.

Experience developing cross-organizational clinical pathways, partnership models, or integrated health and social care services is considered an asset.

Experiencefacilitatingco-design, stakeholder engagement, or community engagement processes is considered an asset.

Experience with systems design, quality improvement, implementation, change management, evaluation, population

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📌 Lead Physician- Population Health Clinic- New Circles (Ontario)
🏢 Flemingdon Health Centre
📍 Ontario