Career Opportunity


Application Due Date: 2024-07-19 15:00

Primary Locations:  Bracebridge, Port Carling

Position Description:  This blended role between MAOHT and CCFHT will report to CCFHT Executive Director and the Remote Care Monitoring (RCM) Project Manager. The RPN will:

CCFHT Chronic Disease Management / MAOHT Chronic Disease Nurse Navigator

  • Assist in the development and provision of evidence-based disease prevention and/or chronic disease management educational and/or rehabilitation programs.
  • Initiate nursing interventions and strategies based on the best available evidence to assist individuals, families, and groups.
  • Conduct patient assessment and education appointments.
  • Encourage patients to take action for their own health and wellness.
  • Promote partnerships with community groups.
  • Collaborate with primary care providers, hospital discharge planners/patient flow navigators, other program managers.
  • Support patients and their families or care providers to facilitate living at home with chronic disease safely and as long as possible.
  • Partner with Home and Community Care (HCC) and Community Paramedics to support intake into the RCM program that will best meet the patient needs.
  • Develop education and implement clinical pathways within digital RCM.
  • Monitor eligibility criteria, length of stay and discharge criteria for patients with CHF, COPD, or frail elderly.
  • Promotion of RCM and patient navigation within primary care offices and hospital discharge planners to provide stability for patients with chronic disease and reduce ED visits and hospital admission rates for patients with CHF and COPD.  
  • Assist with identification of quality indicators and support data collection.
  • Supports a patient-centric, population based, quadruple aim approach to program implementation and management.
  • Work with FHTs rehabilitation program and community partners to ensure patents receive access to various programing available to them at appropriate times in their chronic disease journey. 


  • Registered Practical Nurse (RPN), member in good standing with the College of Nurses of Ontario.
  • Interest and ability to work with an interdisciplinary team.
  • Experience in disease prevention and chronic disease management.
  • Experience in provision of health education to patients.
  • Ability to travel locally and provide own transportation.

Qualifications (Continued):

  • Strong interpersonal, communication, and organizational skills.
  • Previous education/certification in smoking cessation, diabetes management, COPD, chronic condition management, heart health, etc. would be an asset.

Compensation:  $26.00 – $28.00/hour based on experience and participation in Healthcare of Ontario Pension Plan (HOOPP).

Application deadline:  Interested applicants should forward resume and cover letter to Amy Fraser, Executive Assistant, at on or before July 19, 2024.    

Cottage Country Family Health Team is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to race, colour, religion, gender, gender identity or expression, sexual orientation, national origin, disability, or age.