Registered Nurse - CDM Program- Alliston FHT (Alliston)

Organization Name
Alliston Family Health Team
Registered Nurse - CDM Program
FTE Type
1.0 FTE

36 Victoria Street West P.O Box 280

Closing date


The Chronic Disease Management RN (CDN) works collaboratively with physicians, and allied health professionals in the family health team; clients’ and community organizations, to enhance efficient delivery of client centered chronic disease education and care. Understanding the community's unique demographics and based on standardized protocols and guidelines the CDN creates and/or utilizes best practice adult learning tools and other resources to address primary, secondary and tertiary prevention of a variety of chronic diseases and their complications while fostering self-management. The CDN remains current in their knowledge of a variety of chronic diseases, with a focus on disease prevention as well as disease management. The CDN may travel to affiliated physician clinics to provide primary care chronic disease management programming. The position of CDN functions in a manner consistent with, and supports the mission, vision and values of the Alliston Family Health Team.


  • Function and duties include but are not limited to the following:
  • Provides individual and group education specific to a variety of chronic diseases
  • Assesses, plans, implements and evaluates care of clients living with a variety of chronic diseases.
  • Supports clients’ self-management of chronic disease for optimal independence.
  • Maintains familiarity with self-management tools and resources.
  • Acts as a navigator; linking clients with chronic disease and their support persons to available resources.
  • Collaborates to develop, modify and share teaching content including tools and resources to ensure equitable quality programming regionally.
  • Encourages appropriate referral processes for clients.
  • Participates in orientation and ongoing training of staff in the delivery of chronic disease care as required.
  • Supports population health chronic disease prevention initiatives such as screening and prevention strategies


  • Baccalaureate degree in nursing an asset
  • Current, active registration with College of Nurses of Ontario and a member in good standing.
  • Certificate in Adult education, community care, chronic disease management beneficial
  • Current Basic Life Support.


  • Knowledge and skills in the assessment and therapeutic intervention for a variety of chronic diseases.
  • Sound knowledge of learning principles for adults.
  • Program development knowledge.
  • Interest in care of well women and well babies


  • Minimum two years chronic disease nursing experience preferred.
  • Minimum two years of primary care nursing experience preferred.
  • Experience in community care nursing an asset.
  • Program development experience an asset.


  • Advanced nursing skills utilized in the assessment and care of clients with a variety of chronic disease and ability to source appropriate supports in both community and interdisciplinary teams.
  • Demonstrative knowledge of determinants of health and health equity.
  • Advanced communication skills with ability to effectively connect with patients in person and virtually.
  • Embodies a patient and compassionate approach to delivery of care.
  • Excellent motivational interviewing skills.
  • Able to provide episodic care under a medical order or directive and work independently or as part of a team.
  • Must be team focused and flexible; works collaboratively with the interdisciplinary team and physicians.
  • Easy going, able to adapt to new and varied situations.
  • Interest and experience in program development and group program delivery.
  • Ability to multi-task, work under pressure, and meet deadlines.
  • Knowledge and experience in system navigation.
  • Experience with home visits, and coordinated care planning.
  • Interest and experience in disease prevention and health promotion.
  • Understanding of the Chronic Disease Management and Patient Self-Management models of care.
  • Proficiency in the use of computer and with Electronic Medical Records (EMR). PS Suites experience would be an asset.
  • Valid Ontario Driver’s license.


  • The incumbent functions autonomously on a day-to-day basis and manages assigned duties accordingly.
  • Will be required to travel throughout the region and potentially to different clinic sites as duties may require.


The incumbent contributes to making the organization safe for clients and staff and recognizes the importance of reporting unsafe situations and participating in follow up reviews as a learning opportunity.

  • Provides a safe environment by ensuring the adherence to Workplace Safety and Health Regulations and Policies and Infection Control Guidelines. Obeys all safety and health rules and follows recommended Safe Work Procedures. Informs supervisor of any unsafe acts, work conditions, incidents, near misses, injuries or illnesses immediately.
  • Demonstrates a working knowledge of Workplace Hazardous Materials Information Systems (WHMIS) and adheres to procedures for handling and storing controlled substances as described in the Material Safety Data Sheets (MSDS). Uses personal protective equipment as required.
  • Demonstrates understanding of role and responsibilities in fire prevention and disaster preparedness and participates in safety and health training programs including the health facility’s Fire, Disaster and Evacuation Plan.


  • Participates in and demonstrates an understanding of patient safety principles and practices into all day to day activities. Follow all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to patient safety.

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