Primary Health Care Coordinator

You need to sign in or
create an account to save a job.

The Four Villages Community Health Centre is an equal opportunity employer and encourages resumes from people who are reflective of the diverse communities we serve.


Are you looking to work where your excellence will shine, professional standards are highly valued, and quality of care is respected? Do you want to practice in a setting where your voice helps shape how health care is provided; where you work at the centre, in the community and in collaboration with other health care services in West Toronto?


The Four Villages Community Health Centre provides primary health care to the communities in West Toronto in the context of the broader social determinants of health. Our primary care, clinical services and a wide range of health promotion programs are available to all residents with a focus on seniors, families with young children, youth and newcomers. Four Villages has two locations in the west end of Toronto. It is funded by the Ontario Ministry of Health and Long-term Care.


We have a committed team of professionals – family doctors, nurse practitioners, registered nurses, chiropodists, physiotherapists, occupational therapist, dietitians, social workers, therapists, community health workers and administrative staff. As a valuable member of our inter-professional primary health care teams, the Primary Health Care Coordinator works closely and in collaboration with all primary care providers within Four Villages. We are seeking an experienced Registered Nurse to fulfil this role and as a key member of our inter-professional teams. This is a unionized position.



This is an innovative role seeking to evolve the way in which Primary Health Care Services are provided in Ontario through streamlined and coordinated care with the Toronto Central LHIN. The Primary Health Care Coordinator actively collaborates with clients, caregivers, primary care and allied providers within the organization and with external partners. This position will develop and execute coordinated care plans (CCP) based on client care goals to improve the care/supports for those clients with complex health needs to help maintain their well-being and independence in the community. The Primary Health Care Coordinator, with the assistance of Community Health Workers, mental health case managers and Toronto Central LHIN home and community care staff for wider system navigation, supports and coaches clients and their families/support persons in actively coordinating care within Four Villages as well as externally with other agencies. In addition, the Primary Health Care Coordinator creates formalized care teams consisting of multiple types of providers both internal and external to Four Villages. The Primary Health Care Coordinator also functions as a liaison between internal and external service providers, specialty medical clinics and the client and their family/support person.


The Primary Health Care Coordinator works within the framework that appreciates the impact of the social determinants on wellbeing and health as well as places an active emphasis on disease prevention and health promotion.



  • Coordinate client care on an on-going basis:
    • Develop comprehensive coordinated care plans (CCPs), taking a dynamic approach
    • Be the point of contact for clients with respect to any care coordination issues and health needs
    • Ensure implementation, evaluation and revision of the CCPs, while monitoring care and progress towards goals and advise care team members of any new information as relevant to their role in the care for the client
    • Engage the formalized care team as required to manage care transitions or address changes in care status or client needs
    • Provide support and guide clients in making appropriate decisions to enable independence through various communication and coaching methods
    • Offer emotional support to clients and their families/support person
    • Works closely with Toronto Central LHIN and mental health partners to ensure coordinated, quality and timely care and follow-up
  • Performs physical assessments, treatment, triage, health education, and other clinical activities, for care coordination clients, according to the College of Nurses of Ontario standards and full scope of nursing practice; 
  • Assist Four Villages’ providers in identifying complex clients requiring CCPs
  • Reach out, connect with and support Four Villages’ clients experiencing high clinical health service utilization to better support them through inter-professional care (internal and external) via CCPs
  • Ensure effective referral relationships across community agencies, social supports, and other service providers
  • Facilitate positive relationship building and communication between clients, families, support person and their providers
  • Provide education to the clients and training to Four Villages staff, as needed, to assist with navigating health care and social services
  • Maintain complete and accurate client records and any other required documentation
  • Maintain accurate data regarding activities and provide regular and full reporting as required
  • Incorporate and strengthen collaborative and interdisciplinary work
  • Provide instruction, support and consultations regarding CCPs to staff, students and volunteers
  • Work during both regular and extended hours in locations identified by Four Villages (on-site and off-site)
  • Travel between sites and services and accompany clients to appointments as needed
  • Respect and value the diversity of communities and individuals
  • Perform duties as assigned by the supervisor



  • Registered Nurse with appropriate regulatory college registration
  • University degree
  • Experience in Case Management/Care Coordination
  • Experience working with individuals with complex health and/or mental health issues in a community setting
  • Strong assessment and clinical skills
  • Commitment to and knowledge of community health care and community outreach strategies
  • Open-minded, non-judgmental with a commitment to upholding the rights and dignity of all people and respecting their diversity
  • An ability to engage, motivate and coach clients to meet their goals
  • Training in therapeutic/counselling modalities, including CBT, mindfulness, relaxation, DBT, and coaching
  • Demonstrated ability to work within an inter-professional team environment and strong interpersonal skills
  • Proficiency in the use of computers, and various software applications and client information management systems
  • Excellent communication, decision-making, problem-solving, conflict management skills to effectively advocate on behalf of clients
  • Familiarity and understanding of Population Health and Equity in Health Care including an understanding of Anti-Racism and appreciation of Anti-Racism in the Ontario and Canadian context, and in particular Anti-Black Racism and Anti-Indigenous Racism;
  • Second language, relevant to catchment area populations, is an asset



Hours of work:          35 hours per week, at least one evening per week is required


Salary:                        Salary range $60,680 - $73,109 per annum, plus 20 paid vacation days, 10 paid professional development days and excellent benefits.


Pension:                     Four Villages is a HOOPP employer.


We thank all the applicants for their interest and advise that only those selected for an interview will be contacted.


If you have any requirements for accommodation due to disability, please advise Human Resources during the recruitment and selection process. We will work with you to best meet your needs as per the resources available to us.


Four Villages is a scent-free environment.