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Telehomecare Clinician

Closing Date:
Open until position filled
Job Summary:

​Two Permanent Full Time Telehomecare Clinician positions are available with the South West CCAC London location.  Hours of work to be daytime, Monday to Friday. Telehomecare is a patient-centered approach in the delivery of efficient and effective care to people with chronic disease.  Leveraging information and communications technology (ICT) to remotely link providers and clients, Telehomecare provides a targeted and rapid response from the care team to an emerging health crisis, as well as proactive patient coaching, education and coordination of care amongst multiple care providers.  

Demonstrated benefits of the Telehomecare program include:

  • Improvements in participant ability and action to manage their health
  • Decreased hospital readmissions and utilization of emergency departments and walk-in clinics
  • Improved self-reported quality of life and health outcomes


The Telehomecare Clinician provides remote patient monitoring, health coaching, and disease-specific education to patients with complex chronic diseases.  It is based on a collaborative model of care that focuses on enabling the patient to better manage his/her chronic disease through the support of clinician monitoring and coaching.  The Telehomecare Clinician works in collaboration with the patients' circle of care.


Reporting to the Telehomecare Program Lead responsibilities include:

  • Conduct eligibility for any referred patients
  • Create and implement a customized care plan with patients that best meet the patient needs
  • Assist patients in establishing and implementing self-management goals
  • Support patients in medication awareness and management
  • Monitor patients and respond to alerts using established clinical protocols and guidelines
  • Respond to patient phone/email inquiries and determine clinical next steps
  • Deliver patient education using validated educational tools and resources
  • Conduct regular and just-in-time health coaching sessions with patients
  • Remotely monitor and manage an assigned patient case load
  • Conduct home visits and face to face assessments where required


Your qualifications and experience include:

  • Registered Nurse with membership in good standing with a regulatory body in Ontario
  • At least 3-5 years of recent or previous clinical experience with chronic disease management (experience in community setting is considered an asset)
  • Excellent knowledge and expertise working with complex chronic diseases including, but not limited to: CHF, COPD, palliative care, mental health, chronic kidney disease and diabetes
  • Foundational knowledge in clinical practice, decision-making, critical thinking, leadership, research utilization, resource management and problem solving skills
  • Proficient with adult health education delivery, health coaching techniques and patient self-management support (experience with motivational interviewing counseling an asset)
  • Experience in patient centered models of care where patient experience is a priority
  • Maintain professional competencies in Telehomecare best practices, chronic disease management and patient self-management and/or motivational interviewing techniques through ongoing learning and development
  • Knowledge of South West CCAC business strategies, objectives, priorities and programs, and related Client Services priorities and plans
  • Knowledge of the evolving role of CCACs, and the issues and priorities within the healthcare sector and how these impact client service delivery
  • Practical knowledge of relevant legislation (e.g., Long-Term Care Act, Nursing Homes Act, etc.) Knowledge of South West CCAC administrative practices and procedures
  • Effective communication skills to establish and maintain a range of contacts with health professionals, service providers and organizations within the community
  • Effective communication and listening skills specific to communicating through technology, facilitation and care delivery
  • Comfortable and strongly interested in rendering patient care and counseling using telephone, Telehomecare technology and best practices to remotely monitor patients and support self-management
  • Period Travel throughout the South West region may be required
  • Proficiency in French an asset

To apply for this position, please visit  Application deadline is February 27, 2017.

We thank all applicants; however, only those invited for an interview will be contacted.
Accommodations are available for applicants with disabilities throughout the recruitment process. If you require accommodations for interviews please inform Human Resources.
We welcome applications from people of diverse backgrounds.

About the CCAC

Community Care Access Centres (CCACs) connect people across Ontario with quality in‐home and community‐based health care. CCACs provide information, access to qualified care providers and community‐based services to help people come home from hospital or live independently at home.