The Centre for Family Medicine is currently seeking a REGISTERED PRACTICAL NURSE (RPN) to join the KW4 Community Ward In-Home Team for 4-5 days per week. This is to cover a 12-18 month maternity leave.

The KW4 Community Ward-In Home (CWT) is an inter-professional team that delivers in-home primary care to complex patients in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including those who: have complex chronic conditions are living with mental health, psychosocial and/or addictions challenges are very frail or have frequent falls are not managing well, or are not getting the care and support they need are visiting the ER or being hospitalized frequently cannot get to regular office appointments for whatever reason Our team currently consists of part-time nurse practitioner, two full-time outreach workers, a social worker, a chiropractor/mobility specialist, a pharmacist, a consulting physician and a team assistant.

Position Overview The RPN is a key clinical position on the team whose role is to provide preventative and supportive care for patients in their homes, with a strong emphasis on social determinants of health. The RPN operates within their full scope of practice and as directed; and requires initiative and passion in caring for our patient population. They work closely with the whole team, and specifically assist our Nurse Practitioner. There is potential for clinic work also.

Additional Responsibilities

Team Participation Works as both a lead and support to other Team members working with specific patients Required to directly report back and update NP on client’s clinical needs. Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team meetings Ensures that the Team and other stakeholders are kept informed about clinical developments and new and existing patient challenges as necessary Consults with other Team members who have different or enhanced areas of expertise Patient Care Ability to triage, strong med-surgical skills, and excellence in at least one chronic disease (example diabetes, COPD or wound care) Listens to patients to identify their social, physical and emotional needs in order to develop patient specific goals Builds on existing resources and connects patients to additional resources to create a support network Advocates for services as necessary Negotiates with other care providers about how service is provided to ensure patient participation in their own care Follows all safety protocols while working with residents in their home/community and clinic Documentation and Records Management Participates in the development of care plans (CPs) Documents and maintains clear records in an EMR of each patient visit including supports, services and gaps Provides clear and timely communication with other healthcare and social service providers Other correspondence as required Qualifications and Experience: Current CNO Certificate as RPN Updated CPR certification Demonstrated ability to work independently within the RPN scope of practice 3 years of experience in healthcare, preferably working with complex patients Experience working directly with people from diverse, racial, ethnic and socioeconomic backgrounds. Preferred experience or education in primary health care and an adult specialty Ability to triage, strong med-surgical skills, and excellence in at least one chronic disease (example Diabetes, COPD, or wound care) Demonstrated ability to work collaboratively with other Allied Health Professionals Demonstrated excellence in clinical judgment, health assessment and therapeutic skills Demonstrated experience in social determinants of health Proven relationship building and problem-solving skills Proven ability to keep confidential information regarding patients, health care providers, employees, business operations and team information Demonstrated ability to listen effectively and to build working relationships with patients, families, care partners and other team members Access to a reliable vehicle and a valid Ontario driver’s license are required Experience and/or certification in mental health, geriatrics, addictions, and/or counselling are all assets Closes: May 30, 2025

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