The Chronic Disease Management Clinician will be responsible for the development and delivery of chronic disease management services, self-management and prevention programs to address health needs and priorities of the network’s patient population in liaison with My Health Team partners and inter-professional teams. The Chronic Disease Management Clinician works in partnership with fee for service physicians, community organizations and regional health authorities to provide services and health education programs that maintain and promote the health of the Network’s patient population residing in the community area.

The primary focus of the My Health Team is an enhanced primary care service through integration of healthcare services on health promotion, disease prevention, chronic disease management self-management and linkage with community-based resources.

Experience

• Minimum of two years within the last five years of directly related experience in a healthcare setting.
• Experience in chronic pain management an asset.
• Preference for experience in community-based services and/or primary health care, particularly primary care services.
• Experience working in inter-professional team; demonstrated ability to promote teamwork, collaboration and partnerships.
  

Education (Degree/Diploma/Certificate)

• BSW, OT, PT, BSc PN, RPN, BN, RN, SLP, RD, or related health/human service degree required.
• Knowledge/experience of diabetes management including current practice certification for Certified Diabetes Educator or the ability to attain within 2 years required.
• Certified Asthma and/or Respiratory Educator preferred or the ability to attain within 2 years required.
• Health Behavior Change counseling/Motivational Interviewing training an asset.
• Other training related to assessment and care of chronic disease (including physical and mental health related) an asset.

Certification/Licensure/Registration

• Must be registered and a member in good standing with the relevant regulatory body.
• Requires a valid driver’s license and vehicle to carry out job responsibilities.
• If successful applicant is a Registered Dietitian, must be a graduate of a recognized dietetic internship program accredited by Dietitians of Canada.

Qualifications and Skills

• Proficiency in computer software; experience with electronic medical records preferred.
• Demonstrated ability to promote teamwork, collaboration and partnerships.
• Ability to plan, implement and deliver chronic disease management and self-management programming for individuals and groups.
• Comprehensive knowledge and practice skills required in mental health and its links with chronic disease.
• Ability to initiate and work independently.
• Demonstrated critical thinking and decision-making skills.
• Understanding of a population health approach, determinants of health, and equity, especially as it relates to chronic disease is an asset.
• Demonstrated flexibility required for working in a fast-paced, changing environment.
• Understanding of fee for service family medicine work environment is an asset.
• Excellent interpersonal and verbal and written communication skills required.
• Demonstrates a professional approach in all situations.