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 SUMMARY

We are looking for a Physician Assistant, Registered Nurse or Nurse Practitioner to join our team as a Clinical Care Facilitator (CCF). The 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, primary care, physicians and community partners. Working in partnership with patients and caregivers, the CCF monitors recovery, addresses barriers and supports progress toward recovery.

PRIMARY RESPONSIBILITIES

Clinical Assessment and Recovery Support

- Review referrals, confirm eligibility, assess clinical risk factors, and enroll patients before discharge
- Conduct assessments within professional scope and develop individualized recovery plans and achievable goals with patients and caregivers.
- Provide structured follow-up, monitor recovery progress, identify deterioration or barriers to recovery, and initiate appropriate escalation or transition to ongoing care.
- Support symptom management, functional recovery, and patient confidence in safely recovering at home.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 that support engagement, confidence, and recovery at home.
- Provide evidence-informed education on pneumonia recovery, medications, symptom monitoring, warning signs, and when to seek help.
- Use teach-back and coaching techniques to strengthen understanding, support self-management, and confirm readiness to manage recovery at home.
- Address language, accessibility, technology, and social barriers that may affect recovery and access to care.

Care Coordination and MGH2Home Collaboration

- Serve as the primary point of contact for enrolled patients during the transition from hospital to home.
- Coordinate care with MGH2Home, primary care, physicians, home care, and community partners to support a seamless recovery experience.
- Facilitate referrals, communication, and access to services that address ongoing clinical,functional, and social needs.

Interdisciplinary Practice and Clinical Escalation

- Work collaboratively with physicians, NP/PA colleagues, and interdisciplinary providers to support patient recovery and continuity of care.
- Apply established escalation pathways, communicate clinical concerns promptly, and arrange urgent assessment when required.
- Participate in care planning, case reviews, and documentation to support safe, coordinated, patient-centred care.

Program Development and Evaluation

- Apply evidence-informed practice and clinical guidelines to support pathway delivery and patient outcomes.
- Contribute to the development and refinement of pathway tools, educational resources, workflows, and communication processes.
- Support evaluation and continuous improvement efforts to enhance patient experience, care transitions, and reduce avoidable emergency department visits and re-admissions.

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.

EDUCATION

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

- Nurse Practitioner: 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.
- 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 valuable standing with the College of Respiratory Therapists of Ontario.

EXPERIENCE

- Minimum 2 years of clinical experience in respiratory, acute, community, chronic disease, or older adult care.
- Strong assessment, clinical judgment, and escalation skills, including recognition of patient deterioration.
- Experience supporting hospital-to-home transitions, care coordination, and interdisciplinary collaboration.
- Strong patient and caregiver education skills, including teach-back and self-management support.
- Excellent communication, documentation, and organizational skills
- Knowledge and experience with EMRs, community resources, quality improvement, or service implementation are assets.
- 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.

📌 Clinical Care Facilitator, Community Acquired Pneumonia (Integrated Care Pathway) (East York)
🏢 Michael Garron Hospital
📍 East York