Integrated Clinical Specialist: Complex and Chronic Care

CarePartners is one of Ontario’s largest accredited home health care providers, providing nursing, personal support, therapy and rehabilitation support services for patients of all ages. We care for approximately 72,000 patients each year in homes, schools, clinics, workplaces and retirement homes, through our 24 locations and 22 nursing clinics. CarePartners is proud of its commitment to quality, relentlessly seeking to improve the patient and caregiver experience, promoting a healthy and resilient workplace culture, and contributing to a sustainable healthcare system in Ontario.

We continuously innovate to meet patient needs with specialized (award-winning) care programs and technology, including virtual care and AI

The Integrated Clinical Specialist in Complex and Chronic care was established to lead and advance integrated complex and chronic care across the province. We are seeking a highly skilled, dedicated, and self-motivated individual to support the delivery of high-quality, evidence-based care. As a key member of our professional practice team, this position will focus on providing expert guidance, and leadership in multimorbidity and the complexity this brings to the management of care and the need for incorporation of socioeconomic determinants of health along with culture, environment & patient behaviour. 

The Clinical Specialist will play a pivotal role in shaping interprofessional best practices across the patient care continuum, from birth through end-of-life, supporting both clinical teams and patients. This role involves close collaboration with internal and external partners to ensure optimal therapeutic outcomes are achieved. Additionally, the Clinical Specialist will serve as a subject matter expert in skill development, working alongside Clinical Practice Leads and the Learning and Development team to foster ongoing professional growth.

This is a Full-Time position that will include planned travel throughout Ontario as required. 

• Competitive salary, comprehensive health and dental benefits
• Other employment perks such as Employee Assistance Program, Perkopolis, Rewards Points
• Flexible work from home arrangements supporting employee work life balance
• Inspiring leadership and opportunities for professional growth
• Supportive & dedicated Safety Health & Wellness team & Pandemic Response team
• Interprofessional collaboration with our Professional Practice Research & Education Team

Advance Standards of Care and Professional Practice in Complex and Chronic Care

• Champions a culture that is committed to and passionate about patient-centred, high-quality and integrated care and the identification of transformative opportunities in enabling point-of-care excellence in every patient and caregiver interaction.
• Promotes and maintains the application of standards of care, best practice and/or core competencies into the development of processes and policies supporting complex and chronic care practice in home and community care
• Reinforcing the inclusion of socioeconomical, cultural & environmental dimensions as an essential part of person specific factors in the delivery of care and clinical decision making.
• Elevating the knowledge of chronicity and complexity beyond usual care and health outcomes.
• Using a proactive approach to early identification and ongoing support in this vulnerable populations.
• Leads the co-design, implementation and evaluation of the complex & chronic care program at local branches that align with current standards, evidence-based practice, organizational needs and external customer requirements.
• Collaborates with interprofessional patient care teams, operations and quality and professional practice leadership supporting the implementation of local, regional and provincial strategies that will advance excellence in clinical wound care outcomes from a population health lens.
• Promoting education in multimorbidity and person specific care planning.
• Implements evidenced based pathways and programs using an integrated care delivery approach including understanding and elevating the roles of ALL health care professionals (e.g., Personal Support, Therapies and Nursing).
• Maintains clinical competency for front line teams in chronic disease management principles.
• Utilizes instructional design concepts and approach to develop, deliver and coordinate complex and chronic education.
• Develops and implements coaching and mentoring programs for staff to ensure the delivery of best practices.
• Provides complex and chronic disease expertise to diverse populations.
• Facilitates and champions innovative practices, approaches and programming in alignment with CarePartners research initiatives.
• Participates in the development, maintains and monitors quality practice indicators to ensure ongoing practice fidelity.
• Participate in the on-call rotation for remote support with members of the clinical practice specialist team.

Build Capability and Education

• Provide consultancy service and support to leadership and frontline staff to promote practice and programming excellence in accordance with CarePartners' internal and regulatory standards.
• Supports the consistency of complex and chronic care practices across the branches.
• Works closely with operations, learning and development, and quality and risk leadership to collaborate on initiatives such as clinical orientation, role development, and clinical competencies development.
• Is a resource to facilitate the full scope of practice for team members.
• Provides input into the performance appraisal and joint evaluation for CarePartners nurses pertaining to complex and chronic care.
• Champions the use of digital learning platforms and identifies infrastructure necessary to enable agile and responsive learning for frontline team members.
• Supports local site-specific training and coaching initiatives that are informed by key performance indicators, such as patient experience, outcomes measures and risk events.
• Utilizes instructional design concepts and approaches to develop, deliver and coordinate complex and chronic care management.
• Designs educational curriculum on complex and chronic care, integrating adult learning principles into all education programs.
• Assists in the development of communication with evidence-based clinical and research content, e.g., quality and professional practice clinical updates, company newsletters.
• Incorporates adult education principles into any education programs.

Research and Policy

• Identify and participate in research opportunities that are appropriate for the complex and chronic care.
• Provides evidence-based clinical input into the development, maintenance and implementation of clinical and research policies for nursing, therapy and personal support services.
• Participates in attending conference(s), abstract writing, and speaking at conferences pertaining to complex and chronic care.

Special Projects

• Brings leadership from a professional practice lens to strategic priority projects and programming, as required.
• Leads and participates in internal project teams and committees as assigned.
• Other duties, as assigned.

• Registered with the College of Nurses with expertise in complex and chronic care programs such as Diabetes, COPD, CHF, Dementia, Dialysis
• Master’s Degree in Nursing or working towards is preferred.
• More than 5 years of healthcare-related experience in leading clinical practice in home and community care is an asset.
• Experience with knowledge translation, social prescribing, and program management is required.
• Experience with senior friendly care frameworks and specialized geriatric programming.
• Practical knowledge of depression scale and assessment.
• Knowledge of and experience with social prescribing.
• Experience with complex/chronic pediatric care an asset.
• Skilled at researching and developing content for best practice pathways and skills training.
• Demonstrated knowledge of change management principles and performance evaluation.
• Proven ability to collaborate with internal and external stakeholders.
• Strong organization, communication, problem-solving and analytical skills, influencing and negotiation skills, and presentation skills required.
• Strong written communication, proofreading and editing skills required to draft and/or generate correspondence/documents
• Ability to multi-task with attention to detail, demonstrate organizational, prioritization, and time-management skills, and have proven ability to meet deadlines.
• Strong proficiency in all aspects of Microsoft Office, with proven skills in Word, PowerPoint and Excel
• Demonstrated ability to handle highly sensitive and confidential information.
• Ability to travel within Ontario on an occasional basis.
• Valid driver's license, own vehicle and appropriate insurance

In addition to providing home-based health care, CarePartners also serves the community through clinics, transitional care units, and provides relief in retirement homes and shared care settings. Through our Community Nursing Services outreach program, we’ve been organizing staff-led medical care and clinics in countries with poor access to health care since 2009.

CarePartners welcomes and encourages applicants from people with disabilities. Candidates can request accommodations at any time in the hiring process.