CCFHT Manager of Integrated Care

About CCFHT

Cottage Country Family Health Team provides comprehensive, team-based primary care across South Muskoka. Our interdisciplinary teams work collaboratively with physicians and community partners to improve access, quality, and health outcomes for the communities we serve.

Cottage Country Family Health Team (CCFHT) is an interdisciplinary primary care organization serving communities throughout South Muskoka. Working in partnership with family physicians, Nurse Practitioners, Registered Nurses, Registered Practical Nurses, mental health clinicians, social workers, dietitians, pharmacists and other health professionals, we are committed to delivering accessible, coordinated and patient-centred care close to home.

CCFHT is entering an exciting period of growth and transformation. We are evolving our model of care to strengthen team-based primary care, improve access, better integrate our interdisciplinary health professionals, and develop consistent clinical pathways that connect patients with the right care, from the right clinician, at the right time.

We are seeking an experienced and collaborative Manager of Integrated Care to help lead this transformation.

The Opportunity

Reporting to the Executive Director, the Manager of Integrated Care provides operational and clinical leadership to CCFHT’s interdisciplinary health professionals and plays a central role in designing, implementing and continuously improving our future model of primary care.

The Manager will support a diverse team of regulated and non-regulated health professionals working across multiple communities and clinical programs. They will work closely with the Executive Director, physicians, Nurse Practitioners, administrative leadership, community partners and frontline team members to create an integrated system of care that makes the best use of the skills and expertise available across CCFHT.

A significant focus of this position will be translating CCFHT’s future Model of Care into day-to-day clinical operations — including the development of standardized clinical pathways, interdisciplinary programs, referral processes, team workflows and measures of success.

This is an opportunity for a leader who enjoys building, improving and redesigning systems of care while remaining closely connected to frontline teams and the communities they serve.

Key Responsibilities

Integrated Care Leadership

• Provide leadership, coaching, supervision and support to CCFHT’s interdisciplinary health professionals, including Registered Nurses, Registered Practical Nurses, social workers, mental health clinicians, dietitians, pharmacists and other current or future clinical disciplines.
• Build a strong, collaborative interdisciplinary team culture centred on patient needs, teamwork, accountability and continuous improvement.
• Support recruitment, onboarding, orientation, performance development and retention of Integrated Health Team members.
• Establish clear roles, responsibilities, scopes of practice and expectations across disciplines.
• Support clinicians to work to full scope while identifying opportunities for enhanced collaboration between professions.
• Promote consistent clinical and operational practices across CCFHT locations while recognizing the unique needs of individual communities.
• Facilitate team meetings, interdisciplinary planning sessions, case discussions and other forums that strengthen communication and collaboration.

Model of Care Implementation

• Lead the operational implementation and ongoing development of CCFHT’s future Model of Care.
• Translate organizational strategy into practical workflows, programs, clinical pathways and team structures.
• Work with physicians, Nurse Practitioners and interdisciplinary professionals to establish a coordinated model in which patients are directed to the clinician or service best suited to address their needs.
• Support the development of effective triage and care-navigation processes.
• Identify opportunities to improve access, continuity, comprehensiveness and coordination of primary care.
• Support the evolution of both attached and unattached patient models, ensuring that interdisciplinary resources are effectively incorporated into patient care.
• Evaluate emerging models and adapt services as organizational and community needs evolve.

Clinical Pathway Development

Lead and support the development, implementation and evaluation of integrated clinical pathways, which may include:

• Chronic disease management, including diabetes, COPD, hypertension and cardiovascular disease
• Mental health and wellness
• Paediatric and well-child care
• Women’s health and reproductive health
• Preventive care, screening and immunization
• Healthy aging, geriatric care and risk prevention
• Medication management and pharmacy services
• Specialty and focused clinics based on population need
• Care pathways for patients who are currently unattached to a primary care provider

The Manager will ensure pathways clearly define:

• Appropriate patient populations and eligibility
• Referral and triage criteria
• Roles of physicians, Nurse Practitioners and interdisciplinary professionals
• Clinical workflows
• Escalation and consultation processes
• Documentation requirements
• Patient transitions between services
• Quality and outcome measures

Quality Improvement & Clinical Excellence

• Foster a culture of quality improvement, evidence-informed practice and patient safety.
• Develop and monitor meaningful measures related to access, patient experience, clinical outcomes, utilization and program performance.
• Identify gaps, variation and opportunities for improvement across programs and sites.
• Use data, patient feedback and staff experience to continuously refine clinical services.
• Support the development and implementation of clinical policies, procedures, standards and practice guidelines.
• Facilitate quality-improvement initiatives using structured improvement methodologies.
• Support incident review, learning and improvement activities where appropriate.
• Ensure clinical programs align with applicable professional standards, legislation, organizational policies and best practices.

Interdisciplinary Collaboration

• Develop strong working relationships with CCFHT physicians, Nurse Practitioners and other clinical leaders.
• Create opportunities for interdisciplinary professionals to participate meaningfully in the design and leadership of clinical programs.
• Promote shared decision-making and co-design with frontline clinicians.
• Help establish clear interfaces between physician practices, Nurse Practitioner-led services, interdisciplinary programs and administrative teams.
• Champion a culture where patients experience CCFHT as one coordinated organization rather than a collection of separate programs or locations.

Program & Operational Management

• Oversee day-to-day operations of Integrated Care Team programs and services.
• Support workforce planning, scheduling, workload management and resource allocation.
• Monitor program capacity and demand and recommend adjustments to services or staffing.
• Participate in annual operational planning, budget planning and priority setting.
• Work collaboratively with the Manager of Operations and administrative team to establish effective operational processes supporting clinical care.
• Support implementation of new programs, staffing resources and funded initiatives.
• Ensure effective use of physical space, technology and organizational resources.

Change Leadership

• Lead teams through significant organizational and clinical transformation.
• Clearly communicate the rationale, goals and expectations associated with changes in care delivery.
• Engage staff early in the design and implementation of new programs and workflows.
• Identify barriers to implementation and work collaboratively to develop practical solutions.
• Build trust and psychological safety while maintaining accountability for organizational priorities.
• Help establish a learning environment where experimentation, evaluation and refinement are encouraged.

Partnerships & System Integration

• Build productive relationships with community organizations, Ontario Health Team partners, hospitals, public health, home and community care, specialists and other primary care organizations.
• Identify opportunities to develop shared or coordinated clinical pathways with system partners.
• Support CCFHT’s participation in broader primary care transformation and integrated care initiatives.
• Represent CCFHT on committees, working groups and collaborative initiatives as required.

Leadership Competencies

The successful candidate will be:

Collaborative
You actively seek the perspectives of others and believe the strongest solutions are designed with the people who will deliver and experience them.

Systems-oriented
You are able to see connections between people, programs, workflows and organizations and translate a strategic vision into an operational model.

Innovative
You are comfortable challenging historical ways of working and exploring new approaches to primary care delivery.

Pragmatic
You can move from ideas to implementation and understand that sustainable transformation requires practical workflows, clear accountability and attention to operational detail.

Relationship-focused
You build credibility and trust with physicians, clinicians, staff, patients and community partners.

Comfortable with change
You can lead effectively through ambiguity while providing teams with clarity, direction and support.

Accountable
You set clear expectations, follow through on commitments and use data and feedback to assess whether programs are achieving their intended outcomes.

How to Apply

Interested applicants are invited to submit a resume and cover letter outlining their qualifications and interest in the position.

Cottage Country Family Health Team is committed to creating an inclusive and accessible workplace. Accommodation is available throughout the recruitment process upon request.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.