KENSINGTON HEALTH

Kensington Health is a not-for-profit, community-based provider of specialized health care services with an energetic and innovative team that cares about making a difference in the health and well-being of the communities we serve. Since our inception, we’ve dedicated ourselves to tirelessly pursuing the best ways to create a system in which everyone has access to healthcare experiences that truly put patient needs first.

Kensington offers a spectrum of clinical and community services, as well as holistic end-of-life care to our community including long-term care, hospice care, community care, caregiver support, diagnostic imaging, cancer screening, eye exams, eye surgery, and eye tissue processing for transplant. Serving thousands of patients, residents and clients every day, Kensington is dedicated to supporting people and their families to live well at every age and stage. Kensington Health has a rich history of serving a diverse community and delivering equitable, comfortable care, that’s close to home.

For additional information about Kensington Health, please visit our website at https://www.kensingtonhealth.org

THE MID-WEST TORONTO ONTARIO HEALTH TEAM (MWT-OHT)

The MWT-OHT  represents a self-organized group of strategically and philosophically aligned community service providers, primary care providers and hospital partners (Our OHT Partners — Mid-West Toronto Ontario Health Team). We share an interest in advancing collaboration and shared accountability for the ~575,000 patients residing in our uniquely urban community and attributed to our network of providers.

We believe, if we can design a health care system that works for our most structurally vulnerable populations, then we will be designing a health care system that works for everyone.

Our near-term focus is on improving care coordination and support for marginalized communities who choose to seek services within the Mid-West Toronto region. Our goal is to co-design care with individuals with lived experience to actively remove the systemic barriers that prevent meaningful attachment to primary care, that obscure clear access points to the network of providers, and that prevent seamless transitions in care between providers.

Embedded in all of the work are the many dedicated primary care providers who work in Mid-West Toronto. The Mid-West Toronto Family Practice Network (MWT-FPN) was established as a non-profit organization that represents the voices of the myriad primary care models practicing in the MWT-OHT region and is leading the planning of primary integration initiatives in the MWT-OHT.

POSITION OVERVIEW

We are seeking a highly motivated and equity-driven Registered Nurse (RN) to join the Mid-West Toronto Ontario Health Team Secretariat at Kensington Health. This role will support the implementation of the newly developed Primary Care Attachment Liaison Model to increase access and attachment to primary care within our community.

In this role, the RN will act as a key clinical point of contact for individuals who have faced barriers to accessing ongoing primary care. The successful candidate will play a central role in facilitating a smooth transition into care by onboarding patients into solo or small practice primary care clinics. The RN will gather health histories, initiate EMR documentation, identify unmet clinical and social needs, and support structurally vulnerable patients as they connect with a new primary care provider.

The successful candidate will have experience working independently across diverse care settings, including small practices or solo clinics, with a focus on connecting patients to appropriate supports. They will have a strong background in program implementation, health system navigation, and applying health equity principles to reduce barriers to care. In this role, the Primary Care Attachment Liaison will navigate unique challenges of small practice settings, including limited administrative support and variable workflows. They will help build processes and foster partnerships across community and primary care sectors to enhance patient access and continuity of care.

This role will be supported by Kensington’s strong clinical and community infrastructure including access to a community of practice of nurses across community and ambulatory care settings and a network of health navigators across Kensington. The successful candidate will have a circle of support, collaboration and share learning opportunities across the organization and the OHT.

The Primary Care Attachment Liaison Registered Nurse (RN) will report to the Director overseeing the Health System Planning and Primary Care Transformation team of the MWT-OHT Secretariat and work closely with the Family Practice Network Co-Chairs. This is an exciting opportunity to be part of a new and innovative model of care, aimed at improving how patients are connected to primary care in Mid-West Toronto.

The successful candidate will be part of a collaborative, forward-thinking team and will play a key role in building and shaping this emerging approach. The Primary Care Attachment Liaison will support a welcoming, clinically informed onboarding experience for unattached or newly attached patients, helping to reduce the burden on providers by ensuring key information, screenings, and supports are in place before the patient’s first visit. This role is central to the MWT-OHT’s sustainable attachment strategy and supports equity-driven initiatives aimed at improving access to care for patients facing systemic barriers, including those with complex medical or social needs.

RESPONSIBILITIES

• Work with the Central Intake Team to screen and triage patients, determining eligibility for the Primary Care Attachment Liaison Model and ensuring patients are directed to the most appropriate pathway (Primary Care Attachment Liaison Model, direct attachment, or interim supports).
• Conduct pre-visit assessments to gather detailed medical history and social determinants of health.
• Initiate the patient’s Cumulative Patient Profile (CPP) in the Electronic Medical Record (EMR).
• Onboard patients (including those who are structurally vulnerable who face language barriers or have complex care needs) into solo or small primary care clinics adapting workflows to each clinic’s processes and ensuring effective handoff to providers.
• Provide individualized care navigation and referrals to clinical and community services (e.g., cancer screening, chronic disease management, social supports), with a focus on culturally safe and accessible care.
• Act as a liaison between patients and primary care providers, helping to build trust and ensuring patients understand clinic processes and next steps.
• Work closely with the Primary Care Transformation Specialist, primary care physicians, and OHT partners to enable a warm handoff.
• Contribute to the ongoing development, testing and refinement of quality improvement initiatives and the model through opportunity and gap identification, process optimization, data collection, workflow design, evaluation, and scaling.
• With support from OHT colleagues, ensure smooth digital or in-person transfer of patient information.
• Support cross sector partnerships to enhance model adoption sustainability, and scalability across community, primary care, and hospital sectors.
• Demonstrate empathy, professionalism, and clear communication to deliver responsive, respectful, and person-centered service to both doctors and patients.

QUALIFICATIONS

Required Skills and Abilities:

• Demonstrated ability to translate conceptual models into practice and use quality improvement methodologies (e.g., PDSA cycles) to test, refine, and scale new approaches.
• Ability to perform comprehensive health assessments and exercise clinical judgment in triaging patients based on medical and social complexity and identify immediate care needs.
• Demonstrated ability to collaborate effectively with diverse internal teams and external partners, and community stakeholders.
• Demonstrated commitment to and understanding of equity, anti-racism, and anti-oppression principles and practices is required.
• Detail-oriented with excellent time management and organizational skills.
• Excellent verbal and written communication skills, including accurate and timely documentation.
• Sound judgement in identifying and raising process concerns to management.
• Analytical thinker with the ability to apply structured problem-solving approaches.
• Adaptable, self-motivated, and able to thrive in dynamic or evolving care models.

Required Knowledge and Experience:

• Minimum 2 years of experience in primary care, community health, care coordination, or health system navigation.
• Familiarity with Primary Care Electronic Medical Records (e.g., TELUS PS Suite, OSCAR Pro, Accuro, etc.)
• Excellent understanding of the Ontario health care system, primary care delivery models, and solid understanding of local health issues, priorities and needs.
• Demonstrate experience working independently across diverse care settings including small or solo clinics, with a focus on connecting patients to appropriate supports.
• Strong background in applying health equity principles to reduce barriers to care for structurally vulnerable populations.
• Experience onboarding patients, building workflows and supporting clinic staff in smaller or less-resourced practices.
• Experience supporting process design or program evaluation is considered a strong asset.
• Additional leadership experience or responsibilities will be considered an asset.
• Bilingual or multilingual abilities considered a strong asset.

Required Professional Designation/Certificate:

• Registered Nurse (RN) in good standing with the College of Nurses of Ontario (CNO).