Company Description Michael Garron Hospital (MGH) is a community teaching hospital in East Toronto, serving more than 400,000 people across 22 diverse neighborhoods. For over 90 years, MGH has provided high-quality, patient-centered care along the full continuum of health needs, from birth to end-of-life. As a full-service hospital, MGH collaborates with strong community and research partners and is a proud member of East Toronto Health Partners, the Ontario Health Team serving East Toronto. MGH has been recognized as one of Greater Toronto’s Top Employers for multiple consecutive years, reflecting its focus on workplace best practices and staff well-being. The hospital promotes a respectful, kind, and considerate environment, including on its social media platforms, where clear community guidelines support safe and inclusive engagement.
Role Description
East Toronto Care Network (EastTCaN), based at Michael Garron Hospital, is seeking a Physician Assistant (PA) to join our innovative Integrated Care Pathways team as a Clinical Care Facilitator (CCF).
The CCF plays a key clinical role in supporting patients with complex health needs, particularly those living with Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and Community-Acquired Pneumonia (CAP).
Working collaboratively with physicians, specialists, primary care providers, and interdisciplinary teams, the CCF provides direct patient care, supports chronic disease management, facilitates safe transitions from hospital to home, and helps prevent avoidable emergency department visits and hospital readmissions.
Key responsibilities include:
- Conducting patient assessments, clinical follow-ups, and ongoing monitoring.
- Supporting chronic disease management, medication optimization, and individualized care planning.
- Coordinating care transitions between hospital, primary care, and community services.
- Providing patient and caregiver education to support self-management.
- Collaborating with interdisciplinary teams to address complex medical and social needs.
- Contributing to the ongoing development, evaluation, and quality improvement of integrated care pathways.
- This is an opportunity to be part of a collaborative, evolving program focused on transforming how patients experience care across the healthcare system.
