Nurse Practitioner, Clinical Care Facilitator

OVERVIEW

VENT+ Pathway
In partnership with Michael Garron Hospital, the VENT+ Program is an Integrated Care Pathway that supports individuals and family/caregivers recovering from an Intensive Care Unit (ICU) stay, who are at high risk of prolonged ventilation and live with multiple co-morbidities.
Patients in this program are typically adults with moderate to high frailty, complex medical needs, and functional or cognitive changes following critical illness. Many require significant caregiver support and coordination across multiple providers and care settings.
Position Summary
The Nurse Practitioner, Clinical Care Facilitator is a core member of the VENT+ interdisciplinary team, providing advanced clinical care and case management for patients transitioning from ICU to the community.
This role focuses on supporting high-risk patients with complex recovery needs, bridging care across acute, primary, and community settings. The Nurse Practitioner, Clinical Care Facilitator will lead comprehensive assessments, develop individualized recovery plans, and work closely with patients, caregivers, and providers to support safe, coordinated, and person-centered care to optimize the patients recovery.
This role requires strong clinical judgment, comfort with complexity, and the ability to navigate fragmented systems while supporting patients and families through uncertain recovery trajectories.

PRIMARY RESPONSIBILITIES
Clinical Care Delivery

• Provide care within full Nurse Practitioner scope of practice, including assessment, diagnosis, prescribing, and management of complex post-ICU conditions

• Build therapeutic relationships with patients and families during hospitalization to support smoother transitions post-discharge

• Conduct comprehensive initial and ongoing assessments (in-person and virtual), including risk stratification and identification of care needs

• Monitor patient progress through regular follow-ups, including early identification of deterioration and escalation as required

• Develop individualized care plans and SMART recovery goals in partnership with patients and caregivers

• Lead goals-of-care discussions and advance care planning conversations

• Apply geriatric lens to care, including assessment of falls risk, mobility, cognition, mood, polypharmacy, and frailty
Patient and Family Support

• Serve as a primary point of contact for patients and families throughout the care journey

• Provide education, coaching, and support to promote self-management and recovery

• Support caregivers in navigating complex care needs and system challenges

• Connect patients and families to appropriate health and social services
Interdisciplinary Collaboration and Coordination

• Work within an NP-MD dyad model and collaborate closely with allied health professionals (, PT, OT, SW, RPN, RRT, SLP)

• Act as a key liaison across acute care, primary care, and home/community care to ensure seamless transitions

• Proactively identify gaps in care and mobilize appropriate resources across sectors

• Coordinate care with community partners, including rehabilitation services and Ontario Health@Home

• Participate in interdisciplinary rounds and integrated care planning
Program Evaluation and Knowledge Translation

• Actively contribute to a learning health system approach, including quality improvement and pathway co-design

• Support data collection, documentation, and use of tools (, REDCap, virtual monitoring platforms)

• Identify opportunities for improvement and support translation of insights into practice changes

• Work with clerical, project and research support to streamline documentation, enhance virtual monitoring, and collect outcome data.

SALARY

The salary range for this role is $ to $

EDUCATION

•

Required:

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.

QUALIFICATIONS

• Clinical Expertise:
Minimum 3 years clinical experience in critical care, respiratory care, or complex chronic disease management.

•

Collaboration:

Demonstrated experience working in interdisciplinary and cross-sectoral teams to facilitate care transitions.

•…