Position: Palliative Care Nurse Practitioner (NP)

(1.0 FTE Permanent with Benefits)

Reports To: Manager Specialized Care & Programs

Position Summary:

The CFHT Palliative Care Nurse Practitioner (NP) provides specialized, person-centred, community-based palliative care to individuals living with serious, progressive and life-limiting illness. Working within the interdisciplinary model of the Couchiching Family Health Team, the NP provides comprehensive assessment, diagnosis, treatment, symptom management, advance care planning, care coordination and end-of-life care, with an emphasis on supporting patients in the setting that best reflects their goals and preferences.

The NP works collaboratively with patients, families and caregivers, primary care providers and community and regional partners to promote timely, coordinated and continuous palliative care. The role includes direct clinical care for patients with palliative care needs, including eligible individuals who do not have a primary care provider.

In addition to direct clinical care, the NP serves as a palliative care clinical resource to CFHT and community primary care providers through consultation, education, mentorship and capacity building. The NP also contributes to the ongoing development, evaluation and growth of CFHT's palliative care program, with a focus on improving access, quality and continuity of care across the Couchiching community.

Why Join Us:
The Couchiching Family Health Team offers an opportunity to practise in a collaborative, innovative and community-focused primary care environment. This position provides an opportunity to make a meaningful impact through direct care to patients and families while helping strengthen palliative care capacity across the broader primary care and community healthcare system.

The Palliative Care Nurse Practitioner will combine advanced clinical practice, meaningful patient relationships, education, collaboration and program development in a role focused on improving the experience of patients and families living with serious illness.

Roles and Responsibilities:

Clinical Palliative Care:

· Provide comprehensive in-home assessment, follow-up and ongoing clinical management for patients with serious, complex, progressive and life-limiting illness.

· Assess, diagnose and manage complex physical, psychological, social and spiritual symptoms associated with advanced illness, including pain, dyspnea, nausea, anxiety, fatigue, delirium, depression and constipation.

· Prescribe, initiate, adjust and deprescribe medications and other treatments within the NP's scope of practice and in accordance with applicable legislation and skilled standards.

· Develop, implement, monitor and evaluate individualized care plans that reflect each patient's goals, values, preferences, cultural needs and stage of illness.

· Provide timely assessment and management of changing or urgent palliative care needs and symptom crises to support patients in their preferred place of care and, where clinically appropriate, reduce avoidable emergency department visits and hospitalizations.

· Provide ongoing clinical follow-up and continuity as patient needs evolve throughout the illness trajectory, including deterioration and transition to end-of-life care.

· Collaborate with the patient’s primary care provider (PCP), where one is established, to support coordinated, person-centred palliative care and continuity of care

· Provide NP-led palliative care to eligible unattached patients within the defined scope of the CFHT palliative care program, collaborating with other providers and community services to support continuity of care.

Goals of Care, Advance Care Planning and End-of-Life Care:

· Lead and participate in compassionate, timely and person-centred goals-of-care discussions.

· Support advance care planning and shared decision-making with patients, families and substitute decision-makers.

· Help patients and families understand illness, expected disease trajectory, treatment options, prognosis and available supports.

· Facilitate discussions regarding preferred place of care, treatment limitations,



resuscitation and end-of-life wishes.

· Ensure goals of care, substitute decision-maker information, advance care planning and patient preferences are accurately documented and communicated across care settings.

Care Coordination and System Navigation:

· Coordinate care with physicians, nurse practitioners, nurses, social workers, pharmacists, rehabilitation professionals, spiritual care providers and other members of the interdisciplinary team.

· Collaborate with Ontario Health atHome, hospice programs, hospitals, retirement residences, pharmacies, community agencies and other healthcare partners.

· Facilitate transitions between hospital, home, hospice, primary care, and other care settings.

· Support timely access to medications, equipment, home care, respite, financial assistance, transportation and other community resources.

· Participate in case conferences, interdisciplinary rounds and care planning meetings.

· Identify gaps and barriers in patient care and work collaboratively with partners to develop practical solutions.

Patient, Family and Caregiver Support:

· Provide education, anticipatory guidance, counselling and support to patients, families and caregivers.

· Assess caregiver needs and burden and facilitate access to appropriate respite, bereavement and community supports.

· Prepare patients, families and caregivers for anticipated changes in condition and the end-of-life process.

· Support families and caregivers through disease progression, end-of-life care and transition to bereavement.

Consultation, Education and Capacity Building:

· Act as a palliative care clinical resource to CFHT physicians, nurse practitioners, nurses, allied health professionals and other team members.

· Provide consultation and clinical support to community primary care providers caring for patients with palliative and end-of-life care needs.

· Promote a palliative approach to care through mentorship, case consultation, education and knowledge sharing.

· Support the development of palliative care knowledge and competencies across CFHT and with community partners.

· Contribute to educational sessions, clinical rounds and other professional development initiatives.

Clinical Leadership, Program Development and Quality Improvement:

· Contribute to the development, implementation, evaluation and growth of CFHT's palliative care program.

· Identify opportunities to improve access, patient experience, quality and continuity of palliative care services, including for unattached, rural, vulnerable, marginalized and underserved populations.

· Support early identification of patients who may benefit from a palliative approach and facilitate timely assessment and referral.

· Participate in the development and implementation of clinical pathways, protocols, policies, procedures and evidence-informed practices.

· Support the collection, monitoring and reporting of program outcomes and quality indicators, and participate in quality improvement initiatives using data and patient feedback to inform service improvements.

· Identify emerging community needs and contribute to innovative approaches to palliative care delivery.

· Build and maintain robust relationships with internal and external partners to improve awareness, access and coordination of palliative care across the community.

Professional Practice:

· Maintain timely, accurate and comprehensive clinical documentation in the electronic medical record.

· Practice in accordance with the standards and requirements of the College of Nurses of Ontario, applicable legislation, professional guidelines and CFHT policies and procedures.

· Maintain current knowledge and clinical competence through continuing education,



professional development and evidence-informed practice.

· Participate in relevant committees, working groups, team meetings and organizational initiatives.

· Demonstrate professional accountability, sound clinical judgment and a commitment to patient- and family-centred care.

Medical Assistance in Dying (MAID) (Under review, not confirmed)

· Participate in MAID assessments and provision, where appropriate, in accordance with applicable legislation, professional standards, CFHT policies, and the NP's individual scope of practice and competencies.

Qualifications:

Required Qualifications:

· Current registration with the College of Nurses of Ontario (CNO) as a Nurse Practitioner, in good standing and authorized to practice in Ontario.

· Mandatory Declaration of Professional Liability Protection upon hire, and annually thereafter

· Basic Cardiac Life Support (BCLS) Certification required

· Successful completion of an approved Nurse Practitioner education program.

· Minimum of three (3) years of relevant clinical experience in palliative care, primary care, home and community care, oncology, geriatrics or a related clinical setting.

· Demonstrated knowledge and clinical expertise in palliative symptom management, serious illness communication, advance care planning and end-of-life care.

· Demonstrated ability to work independently while functioning effectively within an interdisciplinary team.

· Robust clinical assessment, diagnostic reasoning, communication and care coordination skills.

· Able to work flexible hours including evenings and Saturdays when required

· Valid Ontario driver's licence and access to a reliable vehicle for community-based visits.

· Police Record/Vulnerable Record Check

· It is a condition of employment that you receive the necessary vaccinations to protect against infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental and public health authorities from time to time

Preferred Qualifications/Assets:

· LEAP (Learning Essential Approaches to Palliative Care) certification or equivalent recognized palliative care education.

· Experience providing home-based or community palliative care.

· Experience working in a Family Health Team, Ontario Health Team, Community Health Centre, hospice, home care or other interprofessional healthcare environment.

· Experience providing care to unattached patients and/or individuals with complex medical and social needs.

· Experience with quality improvement, program development, education or clinical leadership.

Core Competencies:

· Advanced clinical assessment, diagnostic reasoning and decision-making

· Palliative care and complex symptom management

· Serious illness communication and goals-of-care conversations

· Patient- and family-centred care

· Interprofessional collaboration

· Care coordination and system navigation

· Clinical leadership, mentorship and education

· Program development and quality improvement

· Strong communication and relationship-building

· Cultural humility and trauma-informed practice

· Advocacy and health equity

· Ability to work effectively in both independent and team-based environments

Working Workplace:

This is a community-based position that includes in-home patient visits and collaboration across multiple healthcare and community settings. The NP must be comfortable working independently in the community while maintaining strong communication and collaboration with the CFHT interdisciplinary team and external partners.

The Couchiching Family Health Team supports diversity, equity and a workplace free from harassment and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection process and workplace. If you are contacted to participate in our recruitment process, please advise the interview coordinator of any accommodations. The CFHT has an Accommodation Policy and Procedure to ensure you have access to a fair and equitable process. While we thank all applicants, only those contacted for an interview will be acknowledged.

Pay: $125,000.00-$128,000.00 per year

Work Location: In person

📌 Palliative Care Nurse Practitioner (Orillia)
🏢 Couchiching Family Health Team
📍 Orillia