A. BACKGROUND

Community Acquired Pneumonia Pathway The East Toronto Care Network (EastTCaN) Community Acquired Pneumonia (CAP) Integrated Care Pathway supports adults transitioning from Michael Garron Hospital to recovery at home. The pathway brings together hospital, primary care, home care and community providers to support transitions, strengthen patient and caregiver confidence, and reduce avoidable emergency department visits and readmissions.

Working collaboratively with MGH2Home (homecare support), the pathway combines individualized recovery planning, education, structured clinical follow-up and access to the MGH2Home respiratory bundle for eligible patients. An initial two-week period of supported recovery focuses on recognizing deterioration, addressing recovery needs and connecting patients with ongoing care.

B. POSITION OVERVIEW The Clinical Care Facilitator (CCF) is a core member of the CAP interdisciplinary team and the primary point of contact for enrolled patients during their transition from hospital to home.

The CCF conducts assessments within their professional scope, develops individualized recovery plans, provides evidence-informed education and structured clinical follow-up, coordinates care with MGH2Home, primarycare, physicians and community partners. Working in partnership with patients and caregivers, the CCF monitors recovery, addresses barriers and supports progress toward recovery.

This position is open to a Nurse Practitioner, Physician Assistant, Registered Nurse or Registered Respiratory Therapist. Clinical responsibilities will be aligned with the successful candidate’s professional scope, demonstrated competencies and organizational policies, including applicable orders, medical directives and physician supervision or delegation arrangements. The role includes access to designated medical support and clear escalation processes.

PRIMARY RESPONSIBILITIES

Clinical Assessment and Recovery Support

- Work with Access and Flow and inpatient teams to review referrals, confirm pathway eligibility and engage patients before discharge.
- Review admission risk information, including CRB-65, and documented discharge stability assessments to inform recovery planning and follow-up needs.
- Conduct initial and ongoing assessments within professional scope, including respiratory symptoms, recovery trajectory, functional ability and relevant clinical findings.
- Identify concerns related to oxygen needs, medication adherence, hydration, nutrition, cognition, frailty, caregiver capacity and the ability to manage safely at home.
- Develop individualized recovery plans and achievable goals with patients and caregivers.
- Provide structured telephone, video or in-person follow-up according to patient needs and the approved pathway.
- Recognize deterioration or unexpected recovery and arrange timely clinical review using established escalation protocols.
- Provide clinical interventions within authorized scope and seek appropriate medical or interdisciplinary input for needs requiring additional expertise.
- Support transition to primary care, community services or another EastTCaN pathway when ongoing needs are identified.

Patient and Caregiver Education

- Build therapeutic relationships with patients and caregivers during hospitalization and throughout recovery.
- Explain expected pneumonia recovery, treatment plans, warning signs and how to access help.
- Use teach-back and coaching to strengthen understanding, confidence and self-management.




- Review the medication plan, identify discrepancies or concerns, and collaborate with the appropriate prescriber or pharmacist to resolve them.
- Reinforce antibiotic adherence, safe activity progression, nutrition and hydration recommendations tailored to the patient’s clinical needs.
- Provide respiratory education, including inhaler technique, oxygen safety and smoking cessation support, within professional competencies.
- Identify language, accessibility, technology and social barriers and arrange appropriate supports.

Care Coordination and MGH2Home Collaboration

- Coordinate with MGH2Home to support assessment for the respiratory bundle and confirm services for patients enrolled in both programs.
- Develop one coordinated recovery plan that clearly outlines clinical follow-up, home services, patient goals and escalation contacts.
- Participate in joint patient reviews with MGH2Home and communicate with home care providers about recovery progress and emerging concerns.
- Clarify responsibilities across the inpatient, ICP and home care teams to support continuity and avoid duplication.
- Facilitate primary care follow-up and communicate relevant recovery information to the ongoing care team.
- Coordinate referrals to rehabilitation, nutrition, pharmacy, social work, Ontario Health atHome and other services as needed.
- Support continuity when MGH2Home services end or patients require additional community care.

Interdisciplinary Practice and Clinical Escalation

- Collaborate with designated physicians, NP/PA colleagues and other interdisciplinary providers to address clinical concerns.
- Apply approved escalation protocols and communicate relevant assessment findings promptly.
- Arrange urgent or emergency assessment when indicated.
- Participate in interdisciplinary rounds and care planning discussions.
- Maintain timely, accurate clinical documentation and communicate care decisions and follow-up responsibilities.

Program Development and Evaluation

- Use current evidence-based research and clinical guidelines to inform pathway development, care delivery and ongoing improvement, working with clinical leads to translate findings into practice.
- Support development of assessment tools, patient education materials, recovery plans and communication processes.
- Support evaluation of enrollment, follow-up completion, patient and caregiver experience, recovery outcomes and acute care utilization.
- Identify service gaps and recommend improvements that strengthen safety, equity and coordination.

EDUCATION

Applicants must meet the requirements for one of the following professions:

- Nurse Practitioner: Current registration as a Nurse Practitioner (RN-EC) in positive standing with the College of Nurses of Ontario (CNO), with Adult or Primary Health Care specialty.
- Physician Assistant: Current registration in good standing with the College of Physicians and Surgeons of Ontario as a Physician Assistant.
- Registered Nurse: Current registration in good standing with the College of Nurses of Ontario as a Registered Nurse.
- Registered Respiratory Therapist:



Current registration in good standing with the College of Respiratory Therapists of Ontario.

EXPERIENCE

- Minimum two years of relevant clinical experience in respiratory care, acute medicine, older adult care, complex chronic disease management or community care.
- Demonstrated assessment and clinical reasoning skills appropriate to professional scope, including recognition of deterioration and timely escalation.
- Experience supporting transitions from hospital to home and collaborating across care settings.
- Experience working with older adults with frailty, multiple conditions or complex recovery needs.
- Strong patient and caregiver education skills, including teach-back and self-management support.
- Ability to manage a caseload, prioritize competing needs and work independently within an interdisciplinary team.
- Strong communication, relationship-building and documentation skills.
- Familiarity with electronic medical records and willingness to use program documentation and evaluation tools.
- Knowledge of community resources and experience in care coordination or case management are assets.
- Experience in quality improvement or implementation of a new clinical service is an asset.
- All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN)

[formerly Toronto East General Hospital (TEGH)] agree to work within the legislated practices of the

Occupational Health and Safety Act of Ontario

- All employees of MGH are responsible to contribute to a transparent culture of patient and staff safety by adhering to and a biding by patient and staff safety policies and procedures set by MGH
- All employees are accountable for protecting the psychological health and safety of themselves and their co-workers through adherence to MGH's policies and practices.

What You Bring

- A commitment to person-centred care, health equity and recovery at home.
- Sound professional judgment and an understanding of when to seek additional expertise.
- A collaborative approach to working with patients, caregivers and partners across organizations.
- Flexibility and initiative to help develop and improve a new integrated care pathway

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 Michael Garron Hospital, we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialized 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, Michael Garron Hospital 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.

This job posting is a confirmed, active vacancy for which we are currently seeking a qualified candidate.

MGH is committed to leveraging new technologies and working efficiently. As a result, artificial intelligence systems may be used as part of our process to screen, assess, and or select applicants for this position.

📌 Clinical Care Facilitator, Community Acquired Pneumonia (Integrated Care Pathway) (Toronto)
🏢 Toronto East Health Network
📍 Toronto