Nurse Practitioner

# Summary 

# About the organization 

 The Community Health Centres of Northumberland (CHCN) is a non-profit, registered charity that has been providing comprehensive, community-based health services since 2008. Established in 2007 and governed by a Community Board of Directors of twelve dedicated local residents, CHCN reflects the diverse strengths, experiences, and perspectives of Northumberland County.

CHCN’s interdisciplinary team of approximately 65 staff includes primary care providers, allied health professionals, dentists, dental hygienists and assistants, community health workers, and social workers. Together, they deliver care through an integrated model of health and wellbeing that recognizes the social, economic, and environmental factors influencing health.

# About the position 

 Job Summary:      

Reporting to the Manager of Specialized Programs, the Nurse Practitioner (NP) provides comprehensive, client-centered primary health care within the Rural Outreach Clinic (ROC), with a focused mandate on improving access for rural and underserved populations. 

The NP delivers care across the lifespan, from well-baby, pediatric care to women’s health, gender-affirming care, mental health, older adult populations, and complex chronic disease management, with a strong focus on health promotion, disease prevention, attachment, and equitable access to care. 

The NP delivers comprehensive primary health care within the clinic and community setting, including outreach activities and home visits, with a focused mandate on improving access in supporting unattached and higher-needed patients in rural and underserved populations, while building and managing an assigned patient panel/roster. The NP is responsible for transitioning clients from episodic access to ongoing, longitudinal primary care. 

The NP functions autonomously within scope while working collaboratively to ensure coordinated, high-quality care. 

Key Responsibilities:

Health Assessment, Diagnosis and Therapeutics:

• Assesses, diagnoses, treats, and follows clients across the lifespan.
• Provides women’s health services, including cervical cancer screening (Pap), contraception, prenatal/postpartum (interdisciplinary with mid-wife), and menopause care.
• Delivers gender-affirming care within scope, including assessment, counselling, hormone therapy (as appropriate), and referral to specialized services.
• Delivers mental health assessment and management, including brief interventions, medication management, and referral as needed.
• Delivers well-baby and pediatric care, including growth, development, and immunizations.
• Provides care to older adults, including frail, cognitive concerns, and complex multi-morbidity.
• Manages acute issues and chronic and complex conditions.
• Orders diagnostic and prescribes medication within scope and as currently designated.
• Initiates and manages the care of clients and/or monitors the on-going therapy of clients with chronic stable illness by providing currently sanctioned pharmacological interventions, appropriate complementary and counselling interventions.

Panel Management & Attachment

• Builds and maintains an assigned patient roster, ensuring continuity and access.
• Attaches patients directly to NP care, prioritizing those who are unattached and have high needs.
• Transitions clients from episodic visits to longitudinal primary care relationships
• Monitors panel needs, access, and follow-up to support safe and effective care.
• Aligns patients to additional services, including MINT/GAIN and community support, as appropriate.

Care Coordination

• Develop practical, client-centered care plans.
• Collaborate with physicians, nursing, and community partners.
• Coordinates care for clients requiring multi-provider involvement, particularly those with complex needs.
• Use group facilitation skills to lead community programs and/or focus groups.
• Provides support and supervision to students who have placements at CHCN.

Documentation & Quality

• Maintains accurate and timely EMR documentation.
• Supports panel management, continuity, and outcome tracking.
• Contributes to program improvement initiatives.

Outreach and Community-Based Care

• Participates in rural outreach activities to improve access to primary care services for underserved and unattached populations.
• Provides home visits, community visits, and mobile/onsite outreach services as clinically appropriate and operationally required.
• Collaborate with community partners and local support to coordinate care for clients with barriers to clinic attendance.
• Supports transitional care, wellness checks, and post-discharge follow-up for vulnerable clients.
• Identifies service gaps and contributes to innovative outreach strategies that strengthen rural access and continuity of care.

Organizational Responsibilities:

• Collects statistical information as required by the Centre.
• Incorporates critical thinking practice and a collaborative approach to problem solving and decision making.
• Integrates into work functions the principles of respect and value for staff, clients, and the community.
• Works in a manner that preserves confidentiality. Adheres to the Personal Health Protection Policy and the Confidentiality Policy for the Centre 
• Works in a manner that seeks to minimize risk to clients, self, the Centre and to staff.  Committed to safety, works in a manner that demonstrates responsibility for following the Centre’s safe work practices and works in compliance with the Occupational Health and Safety Act. Takes responsibility for and is expected to report and unsafe/at risk conditions as well as be accountable for their correction.
• Communicates in a timely and positive manner with the Manager of Specialized Programs regarding job content, specific objectives, and personal performance.
• Identifies performance goals, objectives, and learning needs.  Identifies concerns in a timely manner and, in collaboration with the Manager of Specialized Programs, seeks resolution.
• Participates in team-based care planning and clinic operations.
• Contributes to the evolution of an NP-led rural access and attachment model.
• Incorporates and contributes to the Centre’s efforts for continuous quality improvement by identifying, implementing, and evaluating policies and practices to support best practice. 
• Participates as a team member in all staff functions: program planning, team and inter-team meetings, all staff meetings and team building.
• Performs other duties as assigned.

# Qualifications

•  Registered Nurse in the Extended Class (RN-EC), in good standing with the CNO
• Current professional liability insurance
• Demonstrated experience in primary care, community health, or geriatrics.
• Strong clinical competency in:
  • Women’s Health 
  • Mental health assessment and management
  • Gender-affirming care (or willingness to develop competency)
  • Well-baby care and immunizations
  • Older adult care, including frailty and cognitive assessment
  • Chronic disease management
• Experience managing a patient panel/roster and providing longitudinal care preferred.
• Experience working in rural, vulnerable, or medically complex populations.
• Proficiency with EMR systems
• Current BLS certification
• Valid Driver’s License and willingness to travel within Northumberland County for outreach and home visit responsibilities.
• Demonstrated ability to work effectively within a multi-disciplinary team.
• Ability to work flexible hours, if required, including outreach activities, home visits, community-based care, and participation in rotating on-call services.