GAIN Nurse Practitioner - Senior Persons Living Connected

Jun 11, 2021
Scarborough (Guildwood / Morningside / Ellesmere), Ontario


1 Provide Clinical Care and Consultation Services (Assessment, Diagnosis, Care Plan Implementation, Evaluation)

1.1 Provide Care within the legislated requirement for a full NP Scope of Practice

1.2 Conduct comprehensive geriatric assessment using GAIN model of assessment tools.

1.3 Autonomously diagnose, order, and interpret diagnostic tests; prescribe pharmacological agents, and perform specific procedures appropriate for geriatric patients within the legislated scope of practice

1.4 Collaborate, consult and contribute to inter-professional GAIN Community Team and other health care partners to ensure comprehensive assessment evaluation, analysis, care planning, and interventions that are provided for patients.

1.5 Deliver person-centered care to all patients in accordance with principles of the Behavioural Support Ontario (BSO) project.

1.6 Refer patients to the appropriate health care professionals and community resources to ensure a continuum care.

1.7 Support the effective management of pharmacological agents and their interactions in the development of care plans and interventions. This includes prescribing, tapering, renewing, deprescribing and monitoring.

1.8 Counsel and support patients, caregivers, decision makers and families regarding care planning and consent for interventions.

2 Plan, Coordinate, Implement, Administer and Maintain patient care in collaboration with internal and external providers

2.1 Plan, promote and coordinate evidence- based care for older adults and frail senior’s with complex needs

2.2 Coordinate and support members of the GAIN team

2.3 Collaborate with the inter-professional team, primary care providers, Geriatricians, SPLC’s community support services, and appropriate external providers (Home and Community Care, Hospital Emergency and in-patient departments and community Palliative Care Teams).

2.4 Participate in internal-cluster-based, Community of Practice and regional meetings for knowledge exchange in order to promote continuous quality improvement, education and capacity building in the individual, team, organization, and system.

2.5 Participate in regular meetings with the Director of Care Services and the inter-professional team to assist in program development and ongoing monitoring, policy development, participation in Quality Improvement and Safety and evaluation.

2.6 Lead education and knowledge transfer to all patients and caregivers regarding care plan based on CGA (Comprehensive Geriatric Assessment).

2.7 Evaluate the effectiveness of the care provided to the patient and family, and make recommendations to ensure high quality care

2.8 Participate in systems planning and system integration with the overall goal of ensuring a comprehensive and quality system of care for patients and their families

2.9 Document detailed high-quality consult notes to external healthcare partners, who
are part of patient healthcare teams (i.e. Primary Care Provider, specialist etc.), in a timely manner.

2.10 Collaborate with GAIN team members and external partners to initiate and contribute to Health Links Coordinated Care Plans

3 Ensure patient safety and staff safety in all aspects of responsibilities

3.1. Complies with the SPLC “Client Safety,” “Risk Management,” and “Health and Safety” policies, and other regulated requirements of affiliated professional associations

3.2. Adhere to policies, procedures and department handbook, as required by the position, with emphasis on health and safety for both patients and self

3.3. Identify and report any incidents, hazards, safety concerns, or issues to supervisor, immediately

3.4. Contribute to improvements in processes and practices that supports patient safety

3.5. Educate patients and caregivers about their role in safety, while supporting balance in individual choice and independence

3.6. Comply with, and conform to, all legislated safety regulations while working safely, in accordance with departmental and organizational procedures and policies

3.7. Perform tasks safely at all times

4 Establish and promote health and safety standards

4.1. Contribute and make recommendations to update policies, procedures and handbooks; provide training to patients and caregivers, and monitor Infection Control procedures

4.2. Ensure compliance with patient safety responsibilities, internal policies, procedures, and quality management

4.3. Train patients and caregivers on health and safety supervisory responsibilities; ensure compliance with health and safety legislation, regulations, and internal policies, procedures, and quality management

4.4. Notify inter-professional team of any known hazards and assist in taking steps for prevention of illness or injury

Other reasonable duties that may be assigned from time to time.


  • Master’s Degree in Nursing
  • Completion of the Ontario Primary HealthCare or Adult Nurse Practitioner Certificate Program.
  • Good standing membership with a regulatory body in Ontario (College of Nurses of Ontario
  • Current CPR and First Aid Certificates
  • Canadian certificate in Gerontology an asset
  • Training in P.I.E.C.E.S.TM, Gentle Persuasive Approach, U-First! Montessori, an asset

Skills & Experience:

  • Three-Five (3-5) years’ experience working with older adults and frail seniors
  • Two (2) years recent experience as a Nurse Practitioner in community/health care of older adults and seniors
  • Demonstrated extensive knowledge and skills assisting individuals with various types of Major Neurocognitive Diseases, Behaviour and Psychological Symptoms of Dementia (BPSD), delirium, mental health, addictions neurological conditions and chronic conditions commonly affecting seniors.
  • Strong physical and behavioural assessment skills for diagnosing/evaluating Frailty, Neurocognitive Diseases, deliriums, mental health disorders and addictions
  • Excellent critical thinking skills for the early detection, intervention, and prevention of BPSD.
  • Thorough understanding of the RN(EC) scope of practice and core competency framework
  • Ability to work well within an inter-professional team and to foster effective working relationships
  • Good understanding of non-pharmacological and pharmacological approaches to various chronic conditions common in seniors, neurological conditions, major neurocognitive diseases, BPSD, mental health and addiction.
  • Ability to exercise initiative and observe strict confidentiality
  • Excellent attendance record with ability to maintain the same standard
  • Ability to conduct self ethically and strive to understand and appreciate the diversity of our patient/staff population and community
  • Able and willing to take leadership role in quality improvement initiatives, program developments and evaluation- both locally and regionally
  • Excellent problem solving, adaptability and change management skills.
  • Excellent written and verbal communication, organization and interpersonal skills
  • Ability to read, write, and speak English fluently.
  • Proficiency in other languages desired (Armenian, Cantonese, Greek, Mandarin, Tamil or Urdu)
  • Experience with quality improvement processes an asset

Working Conditions:

  • Required to work at satellite sites (remotely), in patient’s home, in-clinic, and with caregivers,
  • Required to work occasional evening and weekend hours
  • Regular interruptions to support patients’/patients’ needs and crises
  • Regular exposure to computer terminal
  • May be exposed to infectious wastes, conditions, and communicable diseases
  • Interacts with patients, family members, staff, visitors, and government agencies.


Vulnerable Sector Screening required

Access to a vehicle and a valid driver’s license is mandatory

Hours of Work:

  • 17.5 hours work per week

Senior Persons Living Connected is a diverse work environment. We encourage applications from all persons, including persons with disabilities. Accommodation will be provided, if needed, in accordance with the Ontario Human Rights Code and Accessibility for Ontarians Disability Act.

Please submit your application quoting the position you are applying for by email to:

While we thank all applicants for their interest, only those applicants selected for an interview will be contacted.

This job is from CharityVillage
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