Registered Nurse (RN), Locally Driven Population Health Models (LDPHM)

# Summary 

# About the organization 

 LAMP Community Health Centre is a multi-service, community based charitable organization that provides a wide range of programs and services to improve a person's health. LAMP uses a co-ordinated approach to connect people to medical services and other programs that build personal resources. By providing services that improve physical, emotional, social and economic well-being, people can better control their health and environment.

Our organization is grounded in principles of health equity, and we are committed to delivering services and programs through an anti-racism, anti-oppression lens.  We strive to create a healthier community by putting people first and addressing systemic barriers to care.

# About the position 

 Job Summary

At the heart of our work is an interdisciplinary approach that delivers holistic, community-based care – with a strong focus on individuals who experience barriers to accessing health services.  Our team is deeply committed to inclusivity and works within the social determinants of health framework, emphasizing prevention, health promotion, and client education.

Reporting to the Manager, Preventive Care, the Registered Nurse (RN) is accountable for the provision of high-quality nursing care to clients as per the standards of the regulated profession, and in keeping with licensed requirements of the College of Nurses of Ontario. Registered Nurse – Intake will support the Unattached Patients Transition Team, a collaborative initiative between LAMP Community Health Centre, and the West Toronto OHT. This role plays a crucial part in improving primary care attachment for individuals who currently lack a regular primary care provider. 

Primary Responsibilities

• Conduct thorough clinical intake assessments and develop comprehensive cumulative patient profiles (CPPs) for unattached patients.
• Use advanced clinical judgment and triage expertise to determine appropriate primary care providers or care teams.
• Document patient goals and complexity factors to support holistic, person-centred care planning.
• Collaborate closely with CommunitiCare Health, LAMP staff, the Unattached Patients Transition Team, and West Toronto OHT partners to support timely primary care attachment.
• Provide compassionate, culturally safe, and responsive patient interactions aligned with LAMP’s mission and values.
• Utilize digital health tools and electronic medical records (e.g., CareTeam, OceanMD, PS Suite).
• Contribute to staff education, program planning, evaluation and quality improvement initiatives.
• Work collaboratively within and across interdisciplinary teams and community partners to strengthen coordinated care.
• Ensures complete, accurate, and timely documentation of program activities and medical records.
• Monitors for accuracy, quality, and thoroughness through participation in chart reviews.
• Communicates information clearly and concisely to clients and health care providers on a regular basis.
• Experience with case management and case coordination with members of the interdisciplinary team and services within the community.
• Identifies and builds relationships with various community partners.
• Recommends improvements to existing procedures/services.
• Facilitates teamwork and promote group effectiveness.
• Respects people of diverse backgrounds and perspectives.
• Other duties as assigned by Manager

# Qualifications

•  Registered Nurse in good standing with the College of Nurses of Ontario.

• Strong understanding of the Ontario health system, social determinants of health and local community resources.
• Demonstrated commitment to community-based, client-centred care, aligned with equity and anti-oppression principles.
• Experience in community primary care settings.
• Proficiency with electronic medical records and digital tools supporting care transitions; experience with CareTeam, OceanMD, and PS Suite is considered an asset.
• Excellent interpersonal, communication, organizational and time-management skills.
• Experience in program planning and evaluation is an asset.
• Ability to work effectively with individuals from diverse cultural, age, and socioeconomic backgrounds.
• Commitment to LAMP’s values of equity, respect, compassion, collaboration, advocacy and responsiveness.
• Fully vaccinated against COVID-19 for the protection of clients, staff, and community.
• First Aid and CPR is a requirement and must be kept current.
• Valid Driver’s License is an asset.
• A second language is an asset.