Nurse Practitioner, Clinical Care Facilitator

Overview
In partnership with Michael Garron Hospital (MGH), the VENT+ Program is an Integrated Care Pathway that supports individuals and family/caregivers recovering from an Intensive Care Unit (ICU) stay, with a particular focus on patients with multiple comorbidities and complex care needs.

MGH is a recognized leader in prolonged ventilation and the care of patients recovering from critical illness, with significant clinical expertise in supporting recovery, transitions in care, and quality of life. The NP will have the opportunity to work alongside experienced clinicians and thought leaders in this area and contribute to an innovative model of integrated care.

The VENT+ pathway addresses an important gap in care for patients recovering from critical illness. Patients typically have complex medical needs, moderate to high frailty, and functional, cognitive, or social changes following an ICU stay, often requiring caregiver support and coordination across multiple providers and care settings.

VENT+ uses an interdisciplinary, whole-person approach, bringing together occupational therapy, physiotherapy, social work, psychiatry, respiratory care, and other clinical expertise. The team supports patients and caregivers while giving providers a collaborative forum to problem-solve, share expertise and navigate care needs.

The program aims to improve patient and caregiver experience, recovery and quality of life, care coordination, avoidable acute-care utilization, and provider experience and satisfaction.

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.

Working closely with the interdisciplinary team, including OT, PT and Social Work, the Nurse Practitioner leads comprehensive assessments, develops individualized care and recovery plans, and coordinates care across hospital, primary care, specialist and community settings. Over the approximately 18-month pathway, the Nurse Practitioner works in partnership with patients and caregivers to monitor progress, address evolving needs, and support patients in achieving their individual recovery goals.

The role also works closely with primary care providers and other members of the care team to support safe transitions, strengthen continuity of care, and optimize recovery and quality of life.

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…