Chronic Disease Management Registered Nurse - Thames Valley FHT (London)

Organization Name
Thames Valley FHT (London)
Chronic Disease Management Registered Nurse
FTE Type
1.0 FTE

6 - 1385 North Routledge Park
London ON N6H 5N5

Closing date

The Thames Valley Family Health Team (TVFHT) is one of the largest family health teams in Ontario. With more than 115 physicians across 19 sites within London, and Middlesex, Oxford and Elgin counties, the Thames Valley Family Health Team is committed to providing comprehensive inter-collaborative primary health care to over 162,000 patients. Over the past five years, our affiliated physicians have taken on more than 31,000 Ontarians who did not previously have a family doctor.

Supporting the team in Ilderton, the Chronic Disease Management Nurse will provide expertise in self-management for those living with chronic conditions including diabetes, COPD, hypertension, CAD, and more, in one-on-one while proving navigational support to improve patient care in the community.

Primary Responsibilities:

  • Navigating the health care system and engaging community partners
  • Facilitate pathways to appropriate local health and social services
  • Participate in home health nursing to support patients who most benefit from receiving service in the home
  • Ability to provide vulnerable patients with excellent assessment skills through independent consultation
  • Performs clinical services in terms of assessments and treatments
  • Provides health teaching, illness and injury prevention, and clinical recommendations based on appropriate evidence-based standards of practice with patients and families on complex health care issues
  • Provides services for patients with, or at risk of developing chronic diseases such as diabetes, COPD (and related lung health pathologies), hypertension and CAD, etc.
  • Bridge communication gaps between community agencies, TVFHT providers and family MDs
  • Triage patient care utilizing a team approach and community resources within a social context and impacted by social determinants of health
  • Raise the awareness of community services and build patient and family capacity promoting independence and self-management
  • Participates in continuous quality improvement practices consistent with evidence based best practice guidelines


  • Current registration with the College of Nurses of Ontario
  • Experience in System Navigation role an asset
  • Experience in a community setting or combination of community, hospital, public health settings; with experience in a primary care setting an asset
  • Experience in working with frail and elderly with patient advocacy focus
  • Strong assessment skills with the autonomy to triage and respond to the need of vulnerable patients
  • Able to provide episodic care under a medical order or directive, working autonomously in clinic or in the community
  • Knowledge and experience in coordinating care for patients with complex care and mental health issues
  • Knowledge of community partners or services available in the London area
  • Understanding of the Chronic Disease Management and Patient Self-management Models
  • Proficiency in the use of computer and previous experience with an Electronic Medical Record
  • Able to work in a multidisciplinary team to provide optimal patient care
  • Self-driven, motivated, and organized
  • Valid Driver’s License and access to a reliable vehicle

Salary Range: $60,801 - $74,148


To Apply: Interested candidates are invited to submit a detailed resume to the attention of: no later than June 16, 2021 at 4:00 PM. The successful candidate will be required to undergo a criminal background check and medical screening.

To be eligible to apply you must have a Social Insurance Number and in some cases a valid work permit.

While we thank all applicants, only those under consideration will be contacted for an interview. Preference will be first given to any internal Thames Valley FHT candidates.

Thames Valley Family Health Team is an Equal Opportunity employer and committed to hiring staff that reflect the full diversity of the communities where we live and work. Should you require accommodation in making an application, please contact our Support Office. All qualified applicants, including minorities, indigenous, women, veterans, and individuals with disabilities are encouraged to apply.