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Overview

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 care management, incorporating socioeconomic determinants of health along with culture, environment, and patient behavior.

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. 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.

What We Offer

• 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

What the Role Involves

1. Advance standards of care and professional practice in complex and chronic care.
2. Champion a culture committed to patient-centered, high-quality, and integrated care, and identify transformative opportunities for point-of-care excellence.
3. Promote and maintain the application of standards of care, best practices, and core competencies into processes and policies supporting complex and chronic care in home and community settings.
4. Reinforce the inclusion of socioeconomic, cultural, and environmental dimensions as essential parts of person-specific factors in care delivery and clinical decision-making.
5. Elevate knowledge of chronicity and complexity beyond usual care and health outcomes.
6. Use a proactive approach for early identification and ongoing support of vulnerable populations.
7. Lead the co-design, implementation, and evaluation of complex & chronic care programs at local branches, aligning with current standards, evidence-based practices, organizational needs, and external requirements.
8. Collaborate with interprofessional patient care teams, operations, and quality and professional practice leadership to support strategies that advance excellence in clinical wound care outcomes from a population health perspective.
9. Promote education in multimorbidity and person-specific care planning.
10. Implement evidence-based pathways and programs using an integrated care delivery approach, understanding and elevating the roles of all healthcare professionals (e.g., Personal Support, Therapies, Nursing).
11. Maintain clinical competency for front-line teams in chronic disease management principles.
12. Utilize instructional design concepts to develop, deliver, and coordinate complex and chronic education programs.
13. Develop and implement coaching and mentoring programs to ensure best practice delivery.
14. Provide expertise in complex and chronic disease management to diverse populations.
15. Facilitate and champion innovative practices, approaches, and programming aligned with CarePartners research initiatives.
16. Participate in developing, maintaining, and monitoring quality practice indicators to ensure ongoing fidelity to best practices.
17. Participate in the on-call rotation for remote support with team members.

Build Capability and Education

1. Provide consultancy services and support to leadership and frontline staff to promote practice and programming excellence per CarePartners' standards.
2. Support consistency of complex and chronic care practices across branches.
3. Collaborate with operations, learning and development, and quality and risk leadership on initiatives such as clinical orientation, role development, and clinical competencies.
4. Serve as a resource to facilitate the full scope of practice for team members.
5. Contribute to performance appraisals and evaluations related to complex and chronic care.
6. Champion the use of digital learning platforms and identify infrastructure needs for responsive learning.
7. Support local training and coaching initiatives informed by key performance indicators.
8. Design educational curricula on complex and chronic care, integrating adult learning principles.
9. Develop communication materials with evidence-based clinical and research content, such as updates and newsletters.
10. Incorporate adult education principles into all education programs.

Research and Policy

1. Identify and participate in research opportunities relevant to complex and chronic care.
2. Provide evidence-based clinical input into policy development and implementation for nursing, therapy, and personal support services.
3. Participate in conferences, abstract writing, and speaking engagements related to complex and chronic care.

Special Projects

1. Bring leadership from a professional practice perspective to strategic projects and programming as needed.
2. Lead and participate in internal project teams and committees.
3. Perform other duties as assigned.

What You Bring

• Registered Health Professional with expertise in programs such as Diabetes, COPD, CHF, Dementia, Dialysis.
• Master’s Degree in a related field preferred.
• Minimum five years' experience leading clinical practice initiatives within healthcare and home/community settings is an asset.
• Experience with knowledge translation, social prescribing, and program management is required.
• Experience with senior-friendly care frameworks and geriatric programming.
• Practical knowledge of depression scales and assessments.
• Knowledge of social prescribing.
• Experience with complex/chronic pediatric care is an asset.
• Skilled in researching and developing content for best practice pathways and skills training.
• Knowledge of change management and performance evaluation principles.
• Proven ability to collaborate with stakeholders.
• Strong organizational, communication, problem-solving, influencing, and presentation skills.
• Excellent written communication, proofreading, and editing skills.
• Ability to multi-task, prioritize, and meet deadlines.
• Proficiency in Microsoft Office (Word, PowerPoint, Excel).
• Ability to handle sensitive and confidential information.
• Willingness to travel within Ontario occasionally.
• Valid driver’s license, own vehicle, and insurance.

CarePartners In Your Community

CarePartners provides home-based health care, clinics, transitional care, and relief in retirement and shared care settings. Our Community Nursing Services outreach has been organizing staff-led medical care in underserved countries since 2009.

Accessibility

CarePartners welcomes applicants with disabilities and provides accommodations upon request during the hiring process.