Nurse Practitioner

Support a Mission-Driven Team as a Nurse Practitioner!

CANES Community Care is a not-for-profit organization committed to providing outstanding support and care services that enhance the lives of seniors, enabling them to remain in their homes and communities. Guided by our vision — Live well, age well – with CANES Community Care — we foster a workplace culture rooted in our core values:
Reliable, Reputable, Responsive, and Reaching
.

Permanent Part-Time (approximately 14 hours/week)

Hours: Approximately 14 hours/week (2 days/week)

POSITION SUMMARY:

The Nurse Practitioner will be the primary care provider to Transition Care and community clients and works within his/her legislative scope of practice as described by the College of Nurses of Ontario (CNO). This individual will collaborate with the clients, caregivers and families, and the circle of care in the development, implementation and evaluation of the client’s care plan.

The Nurse Practitioner (NP) delivers comprehensive, person-centred care to older adults, including those transitioning from hospital to community settings and supports patients with complex health needs to maintain safety, independence, and optimal health outcomes while living at home.

This role is primarily clinical and client-facing, with a focus on assessment, diagnosis, treatment, and care coordination. The NP plays a key role in stabilizing clients and proactively mitigate avoidable emergency department visits and hospitalizations through timely clinical intervention, ongoing monitoring, and coordinated care planning. He/She will also lead and provide mentorship to the Transition Care staff to ensure quality care for clients are in place.

WORK SCHEDULE & COVERAGE MODEL

• The NP role is structured as a fixed part-time position of approximately 14 hours per week
• Weekly hours are distributed across:
• On-site clinical care and rounds at assigned locations
• Documentation, care coordination, and interdisciplinary collaboration
• Scheduled availability/on‑call coverage periods to support clinical decision‑making and urgent client needs
• On‑call/availability expectations:
• Defined weekly availability windows (to be scheduled in advance)
• Focus on timely clinical guidance and escalation support
• Flexibility required based on client acuity and program needs

ROLES AND RESPONSIBILITIES

Key Responsibilities

Advanced Clinical Practice

• Perform comprehensive health assessments, including physical, mental, and functional evaluations
• Diagnose and manage acute and chronic conditions in older adults
• Provide pharmacological and non‑pharmacological treatment within NP scope of practice
• Order and interpret laboratory tests, diagnostic imaging, and other investigations
• Complete medication reconciliation in collaboration with pharmacy partners
• Monitor client progress and adjust care plans as needed

Transitional Care & Coordination

• Support safe and effective transitions from hospital to community-based care
• Liaise with hospital discharge teams where necessary to ensure continuity of care
• Develop, implement, and evaluate individualized care plans with clients and families
• Participate in care conferences with clients, caregivers, and care team members
• Identify and mitigate risks for hospital readmission or clinical deterioration

Documentation & Communication

• Document all clinical assessments, interventions, and outcomes in a timely and accurate manner as per CNO standards
• Maintain clear communication with clients, families, and the interprofessional team
• Support completion of required documentation such as LTC application assessments where applicable

Client & Family Support

• Provide education on health conditions, medications, and self‑management strategies
• Promote health maintenance, disease prevention, and functional independence
• Engage clients and families in shared decision‑making and care planning

On Call/ Clinical Coverage Expectations:

• Provide remote clinical support (phone/virtual) and guidance to nursing staff and care teams during assigned coverage periods
• Respond to clinical concerns within established response time expectations
• Support appropriate escalation pathways, including in‑person assessment when required

Quality & Safety

• Contr…