BACKGROUND

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.

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 transparent escalation processes.

Primary Responsibilities

- 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

📌 Clinical Care Facilitator, Community Acquired Pneumonia (Toronto)
🏢 Michael Garron Hospital
📍 Toronto