Registered Practical Nurse – Integrated Care Pathways CoordinatorShape the Future of Connected Care with Us
Join an innovative and collaborative team that is transforming how care is delivered across Dufferin and Caledon. Through our integrated Hub-and-Spoke model, supported by centralized intake, a shared electronic medical record, and strong community partnerships, we are creating a more connected, equitable, and person-centred system of care by bringing health, human, and social services together.
We believe exceptional care starts with strong relationships. Working alongside colleagues, community partners, clients, and families, you will help foster a culture of trust, collaboration, advocacy, and respect. Here, you can focus on what matters most: delivering high-quality care and improving outcomes for the people and communities we serve. We support our team members to practice at their full scope while making a meaningful difference in the lives of vulnerable and underserved populations.
As part of our team, you will contribute to innovative solutions, continuous improvement initiatives, and integrated approaches that address complex community needs. We are seeking compassionate, adaptable professionals who are committed to growth, communicate effectively, embrace change, and make thoughtful decisions in support of our shared vision.
If you are passionate about health equity, collaborative care, and making a lasting impact in your community, we invite you to join us in shaping the future of primary care and creating healthier communities together.
The Dufferin Area Family Health Team currently has an opportunity for a full-time Registered Practical Nurse – Integrated Care Pathways Coordinator to join our compassionate, collaborative, multi-disciplinary, dynamic health care team dedicated to supporting patients for improved health and wellbeing.
As a key clinical integrator within the Dufferin Area Family Health Team and the broader Ontario Health Team model, the Registered Practical Nurse (RPN) – Integrated Care Pathways Coordinator drives coordinated access, clinical triage, and seamless navigation across priority clinical streams. Operating across priority pathways, including Musculoskeletal (MSK), Mental Health & Addictions, Specialist Referrals, Palliative Care, and Unattached Patient and Caregivers, this role actively reviews referral completeness, connects clients to multidisciplinary community resources, and leverages digital systems to close referral loops without dropped handoffs. Working alongside Family Physicians, Nurse Practitioners, clinical teams and regional partners, the coordinator turns complex patient journeys into connected, equitable care experiences.
Key Responsibilities
Central Intake Pathway Coordination & Referral Management
- Coordinate, triage, and track clinical referrals across core pathways (Specialist Referrals, MSK, Mental Health & Addictions, Palliative Care, and Unattached Patient Attachment, etc.) to ensure timely, appropriate access.
- Review incoming and outgoing referrals for clinical completeness, aligning patients with local community-based care, pre-referral optimization (e.g., community MSK assessment prior to orthopedic referral), and e-consultation options.
- Utilize central digital referral tools (e.g., Ocean eReferral, Telus PS Suite) to monitor referral progression, manage rejection contingencies, and actively close referral loops.
- Maintain accurate, real-time documentation and tracking across shared EMRs to ensure zero lost referrals across the continuum of care.
System Navigation & Client-Centred Care
- Conduct clinical and social consultations with patients and caregivers to assess complexity, vulnerability, and social determinants of health.
- Support attachment readiness and intake for unattached patient populations, assisting with multidisciplinary “Care Days” and community registry coordination.
- Connect clients with community-based health, human, and social services across Dufferin and Caledon, proactively identifying service duplications and eliminating access barriers.
Collaborative Transformation & Quality Improvement
- Partner with administrative traffic control/referral coordinators, family physicians, nurse practitioners, allied health teams, and hospital partners to optimize regional care pathways.
- Actively contribute to quality improvement initiatives, workflow optimization, and data collection (including PREMs/PROMs and access metrics).
- Champion “System-First” problem-solving by openly sharing data, identifying workflow bottlenecks, and proposing creative solutions to improve overall system flow.
Required Skills, Experience & Cultural Attributes
- Education & Registration: Current registration in good standing as a Registered Practical Nurse (RPN) with the College of Nurses of Ontario (CNO).
- System-First Mindset: Demonstrated ability to look beyond organizational silos, prioritizing whole-patient journeys, timely access, and system outcomes over individual task ownership.
- Adaptability & Initiative: High comfort level working in evolving, ambiguous (“grey”) environments, with the agility to pivot, take initiative, and contribute to emerging models of care.
- Radical Transparency & Collaboration: Strong communication and conflict-resolution skills, with a track record of cross-sector teamwork, psychological safety, and viewing challenges as learning opportunities.
- Digital Literacy: Proficiency with Electronic Medical Records (Telus PS Suite preferred) and digital health referral platforms (e.g., Ocean platform).
- Equity & Inclusion: Deep understanding of health equity, cultural safety, anti-oppressive frameworks, and barriers faced by vulnerable populations.
Why Join Us: Build the Future of Care
We aren’t just filling a position - we are actively transforming healthcare across Dufferin and Caledon. If you are energized by continuous improvement, thrive in dynamic environments where you can shape the path forward, and believe great culture drives real system change, this is where you belong.
- Be a Driver of Real Transformation: Help build connected, equitable pathways from the ground up - moving beyond traditional silos to create seamless journeys for patients and families.
- Thrive in a “System-First” Culture: Join a team that values psychological safety, radical transparency, creative problem-solving, and the courage to challenge legacy norms.
- Make a Measurable Community Impact: Direct your energy where it matters most, closing referral loops, supporting vulnerable populations, and ensuring no patient falls through the cracks.
- Full-Scope Clinical Leadership: Practice at the top of your RPN scope within an innovative interdisciplinary team that actively seeks and implements your ideas.
- Comprehensive Total Rewards:
- Healthcare of Ontario Pension Plan (HOOPP)
- Comprehensive health, dental, vision, and EFAP benefits
- Dedicated funding and support for continuing education and leadership development
- Flexible work options and mileage compensation
- Salary commensurate with the Ministry of Health compensation grid
Hourly Rate: $28.56 – $39.83
This is a hybrid role
Office location is Orangeville-Caledon
Hours are 37.5 hours per week – including one evening shift per week
Vehicle for travel to sites and within community
If this opportunity interests you, please submit a cover letter and your resume to
a.cutt@dafht.ca no later than Friday, October 23rd, 2026.
Come join our team – as together we aim to provide quality health care in a great community!
- The Dufferin Area Family Health Team (DAFHT) welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in all aspects of the selection process. If you are contacted for a job opportunity, please advise the DAFHT of any accommodations needed to ensure you have access to a fair and equitable process. Any information received relating to accommodation will be addressed confidentially. The DAFHT is committed to an inclusive, barrier-free recruitment and selection process and work environment.
