Registered Nurse (RN) – Geriatric Assessor

Position Overview

The Primary Care Registered Nurse (RN) – Geriatric Assessor plays a vital role in supporting older adults with frailty, chronic conditions, and complex health needs within a collaborative primary care environment. As a member of the interprofessional team, the RN works closely with patients, families, and caregivers to enable early identification, assessment, and coordinated management of health challenges, promoting independence and quality of life at home for as long as possible. 

This role involves conducting Comprehensive Geriatric Assessments (CGA), leading care planning, and collaborating with physicians, nurse practitioners, allied health professionals, and community partners. The CGA process aims to reduce disability by detecting and addressing reversible conditions, supporting chronic disease management, and optimizing functional ability. The RN also contributes to system navigation, builds team capacity, and proactively manages complexity to reduce avoidable hospital or specialist use. 

Essential Duties & Responsibilities

Patient Assessment & Care Coordination

• Identify older adults at risk of or experiencing moderate frailty or complexity within the primary care roster using screening tools, EMR data, and provider referrals.
• Conduct comprehensive geriatric assessments (CGA) incorporating medical/surgical history, medications, continence, social history, falls risk, functional status, cognition, mood/mental health, sleep, pain, nutrition, and physical examination, and obtain consent for Primary Care Integrated Geriatric Team (PCIGT) rounds.
• Analyze and synthesize findings from the CGA into a comprehensive clinical report identifying priority needs and relevant treatment options.
• Collaborate with patients, caregivers, and providers to develop goal-oriented, individualized care plans that address health, social, and environmental needs, and consider medical prognosis and comorbidities.
• Review clinical and social information across databases and communication systems to determine whether joint visits with other health partners are appropriate and feasible.
• Provide education, support, and resources to patients and families to promote independence, self-management, and safe aging at home.
• Support advance care planning and shared decision-making discussions with patients and caregivers.
• Recommend activity modifications, compensatory strategies, and assistive devices to promote safety and maximize functional independence at home.

Collaboration & Team Integration

• Works as an embedded member of the primary care team, liaising with Physicians, Nurse Practitioners, Social Workers, Dietitians, and other interprofessional partners.
• Determine which patients should be discussed at PCIGT rounds or referred back to their primary care provider for follow-up and care planning.
• Provide recommendations following assessment to guide next steps, referrals, and interventions.
• Participate in case conferences, care rounds, and interdisciplinary planning sessions to ensure coordinated and holistic care for older adults.
• Offer geriatric knowledge-sharing and capacity-building within the primary care team to enhance confidence in managing frailty and complexity.
• Communicate directly with care teams and community partners to ensure implementation of care plans and facilitate collaboration across care settings.

Service & Quality

• Monitor areas of accountability to ensure appropriate resources are in place to meet demands and provide exceptional care/service. Develop program operational planning: 1-2 year planning horizon.
• Collaborate with physicians, care providers and other internal stakeholder to provide exceptional patient care.
• Collaborate with external partners to align operational planning to patient care/population and/or service delivery needs.
• Champion and model our values, the importance of patient safety and patient focused care. Ensure knowledge and oversight of patient safety concerns/incidents in own area to ensure improvement strategies are considered and implemented.
• Ensure awareness of patient experience scores and trends for applicable departments, support Manager in continuous improvement, remove barriers/ensure the right supports are available.
• Provide guidance, coaching and oversight to ensure required policies, procedures and standards/protocols are in place. Support managers in ensuring critical processes are being followed. Approve department level policy, procedures, and standards/protocols.
• Support Managers in resolving patient complaints as needed, collaborate with key stakeholders to respond formally to concerns/complaints, provide recognition when applicable, ensure knowledge and oversight of trends and opportunities for continuous improvement.
• Champion patients, caregivers, and families as active members of their healthcare team.
• Support Managers, staff and providers in the achievement of high-quality patient care/service delivery, quality improvement and the achievement of successful regulatory body audits, accreditation, quality metrics or other requirements.

Health Promotion & System Navigation

• Promote early identification and management of frailty to help prevent crisis-driven care, avoid hospital admissions, and delay institutionalization.
• Facilitate access to community-based resources and supports to meet health and social care needs.
• Support transition planning between hospital, home, primary care, and community agencies to ensure timely follow-up, equipment needs, and continuity of care.
• Provide ongoing monitoring and follow-up for patients with evolving or complex conditions.

Clinical Documentation & Quality Improvement

• Maintain accurate and timely documentation within the EMR, capturing assessment findings, interventions, and recommendations.
• Document clinical reasoning, client goals, progress, and outcomes according to regulatory and organizational standards, including any required legal, insurance, or community service forms.
• Track and report patient outcomes, identifying opportunities for improvement and participating in quality improvement initiatives related to frailty management and geriatric care.
• Participate in program evaluation, data collection, and performance measurement related to integrated geriatric care initiatives.

Infection Control & Professional Practice

• Adhere to infection prevention and control procedures and safety protocols.
• Ensure patient privacy and confidentiality in all aspects of care and communication.
• Maintain current knowledge of geriatric best practices, clinical guidelines, and community resources.
• Engage in ongoing professional development related to geriatrics, frailty, and primary care nursing.

Knowledge, Skills & Abilities

• Advanced clinical assessment skills, particularly in the care of older adults.
• Demonstrated knowledge of frailty, geriatric syndromes, chronic disease management, and integrated models of care.
• Ability to conduct and interpret comprehensive geriatric assessments.
• Strong knowledge of the psychological, physical, and functional implications of aging.
• Ability to assess cognitive functioning and mental status in older adults.
• Excellent communication and interpersonal skills to build trust with patients, families, and care teams.
• Proficiency in EMR systems (Epic preferred) and data documentation.
• Strong collaboration, problem-solving, and critical thinking skills.
• Demonstrated ability to adapt and respond to evolving patient and program needs.
• Ability to work independently while effectively integrating within a multidisciplinary team.
• Commitment to promoting dignity, autonomy, and quality of life for older adults.
• Extensive knowledge of local community supports and resources available to older adults and caregivers.
• Ability to consistently demonstrate GHC’s values of respect, kindness, compassion, and accountability in all aspects of work.

Required Qualifications

Education, Licensure and/or Certification

• Bachelor’s of Science in Nursing (BScN) or equivalent nursing degree
• Registered Nurse with a valid Certification of Registration in good standing with the College of Nurses of Ontario (CNO)
• Current Basic Life Support (BLS) certification
• Additional education or certification in geriatrics, chronic disease management, or care of the elderly is an asset 

Compensation:

$37.37 – $49.82

Union:

ONA

Positions:

1

Location:

170 East Street

Selection Process:

Please apply through our ADP Career Centre by November 26, 2025.

Interested applicants are asked to submit a cover letter and resume indicating their qualifications for the position by the application deadline.  The ADP Workforce Now Career Centre includes built-in technology that evaluates applications against job posting requirements and assigns a score based on relevant criteria. Those selected for interviews will be required to demonstrate their qualifications and required skills and abilities as outlined above. Group Health Centre is committed to an application and interview process and work environment that is inclusive and barrier free. Accommodation will be provided in accordance with the Ontario Human Rights Code/AODA. Applicants need to make any accommodation requests for the application or interview process known in advance by contacting the Human Resources Department at 705-759-5513. We thank all applicants, however only those under consideration will be contacted.