Couchiching Family Health Team

(1.0 FTE With Benefits)Reports To: Manager, Specialized Care & Programs

Position Summary

As a key member of the Couchiching Family Health Team (CFHT) and an integral part of an interdisciplinary health care team, the Nurse Practitioner (NP) will share expertise in health promotion and disease prevention and help connect patients with appropriate services and professionals. The NP will be responsible for the planning, coordination and delivery of care to older adults, their families and caregivers. The NP will also provide clinical and educational support and facilitate connections across health care sectors for clients requiring complex care in the community.

Why Join Us

Join a collaborative, team-based primary care environment focused on improving access and continuity of care in the community, and be part of a progressive organization advancing Ontario Health’s Primary Care for All initiative.

Roles and Responsibilities

Assessment and Clinical Care

- Conduct comprehensive geriatric assessments incorporating medical, functional, cognitive, psychological and social domains.
- Evaluate cognitive impairment, including dementia, delirium and depression.
- Assess falls, gait, balance, mobility and functional decline.
- Identify polypharmacy, potentially inappropriate medications and medication-related harm.
- Assess caregiver burden, home safety and risks to independent living.
- Recognize atypical presentations of illness in older adults.
- Provide home visits when needed.
- Demonstrate strong clinical judgment when managing older adults with multiple interacting medical, cognitive, functional and psychosocial concerns.




- Prioritize competing medical problems while considering frailty, prognosis, quality of life and patient preferences.
- Formulate and communicate medical diagnoses and evidence-informed management plans.
- Initiate appropriate investigations, treatments (including medications within scope), referrals and follow-up.
- Demonstrate robust organizational skills, effective triage, and appropriate prioritization of workload.
- Work collaboratively with geriatricians, primary care providers, nursing, OT, PT, Pharmacy, Social Work, navigators and community agencies.
- Ensure all notes and patient charts are updated in a timely manner and in accordance with CFHT policies.
- Participate in CFHT and regional committees as needed.
- Maintain and upgrade knowledge and skills.
- Maintain current knowledge of policies and procedures.
- Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy Act.
- Work in compliance with Health and Safety laws adhering to safe work practices and procedures established by the CFHT.
- Adapt to the staffing needs of the CFHT by assisting with Nursing responsibilities in other CFHT programs and services as required.

Collaboration, Leadership and Administration

- Work collaboratively with geriatricians, primary care providers, nursing, occupational therapy, physiotherapy,



pharmacy, social work, navigators and community agencies.
- Consult and collaborate with geriatricians, physicians and other members of the interdisciplinary team to develop and discuss individualized care plans with clients, families and caregivers based on best practice.
- Link clients with community resources, particularly supports for older adults, and share information to support the best possible client experience.
- Communicate effectively with older adults experiencing hearing, cognitive or communication difficulties.
- Demonstrate empathy, patience and respect for older adults and caregivers.
- Navigate challenging conversations involving dementia, declining independence, driving, safety and goals of.
- Provide clinical leadership within the interdisciplinary team.
- Support education and mentorship of nurses, learners and other health professionals.
- Ensure all notes and patient charts are updated in a timely manner.
- Prepare quarterly reports and monitor daily statistical data to ensure statistics are reported to the Ministry of Health in a timely manner.
- Participate in CFHT and regional committees as needed.
- Maintain and upgrade knowledge and skills.
- Maintain current knowledge of policies and procedures.
- Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy Act.
- Work in compliance with health and safety legislation and adhere to safe work practices and procedures established by CFHT.
- Perform other duties as required.

Skills and Knowledge Requirements

- Demonstrated ability to work effectively as

📌 Nurse Practitioner (Canada)
🏢 Couchiching Family Health Team
📍 Canada