Caring for clients in the community and helping them live confidently and safely at home is the core of this nursing role. The Community Health Nurse works independently and collaboratively as part of an interprofessional team, managing a client caseload and providing assessments, coaching, interventions, and follow-up care. This position emphasizes health promotion, maintenance, and restoration, particularly for those with chronic diseases, and facilitates client transitions across the healthcare continuum.
Responsibilities
Establish a therapeutic relationship with clients using interpersonal and interviewing techniques, in person and/or over the telephone, ensuring client choice and autonomy in decision-making and care planning
Screen referrals, provide individualized client assessments, interprofessional care planning, and interventions including clinical care, and referral services for clients with multiple complex chronic conditions
Assist clients to achieve an optimal level of function by facilitating timely and appropriate health services and utilizing a variety of resources and services
Collaborate with the primary care provider, client, family/supports/caregivers, other healthcare professionals, clinics, hospitals, and other community resources to identify and resolve client care issues and coordinate the integration of care and services
Develop a comprehensive shared patient/client care plan in collaboration with the interprofessional team, primary care provider, client and/or family, other healthcare providers, and/or referring clinics
Facilitate and support the transition of the client care plan to the referring source, primary/community care provider, and/or community agencies
Provide direct client care and identify other care services required in accordance with applicable guidelines, policies, and evidence-based best practice
Provide comprehensive explanations of care to the client and family, as appropriate
Make decisions on client-specific direct care tasks; assign direct client care tasks to Community Health Workers and, when appropriate, delegate client-specific direct care tasks to Community Health Workers
Provide in-home demonstrations and training to standards of practice for assigned and delegated client-specific tasks
Ensure that the Community Health Worker has the necessary knowledge, skills, and support to perform the delegated tasks within clearly defined limits
Collaborate with the Community Health Nurse - Licensed Practical Nurse in the monitoring of Community Health Workers performing client-specific delegated direct care tasks
Facilitate care conferencing to review client care plans in collaboration with the interprofessional team and primary care provider to determine timing and referral to other services and/or interventions to improve client outcomes
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Initiate, monitor, and evaluate the appropriateness and effectiveness of the short and long-term care plan to meet specific client goals
Develop next steps in collaboration with the client and family
Develop and support a transition process for achieving client care goals across the care continuum including discharge and/or transfer to other services, as required
Discuss clinical findings with client/family in collaboration with the interprofessional team to develop action plans and set goals directed at clinical needs, self-management, self-care, and improved health-related quality of life
Access system information and resources to review client data such as medical history, progress notes, consultation reports, and lab reports and incorporate findings into the care plan
Plan, organize, and establish priorities by using resources effectively and efficiently
Respond to unanticipated events and/or changing client or service assignment needs, as needed
Support clients and their families before, during, and after interprofessional conferences and clinic visits by providing information through their decision-making process regarding treatment options
Advocate on behalf of the client/family to support their choices and needs and provide direct care to clients within the clinic/community/home as they transition to another program, service, or healthcare provider
Arrange and participate in joint home visits to clients and/or families with other healthcare professionals, as required
Provide advice to the client and/or caregiver about available community resources
Provide health counseling to clients including education, self-management, self-monitoring, and wellness/health promotion/prevention through a combination of clinic, telephone, or home visits
Collaborate with other healthcare professionals in clinics, community programs, and services to facilitate the flow of information through a variety of settings within the primary & community care network
Maintain clinical records such as intake screens, client assessments, clinical interventions, treatment formulations, care plans, and progress notes
Maintain statistical information on clients in accordance with established policies, standards, and procedures
Maintain professional practice growth, knowledge, and expertise to reflect current standards of practice by reviewing relevant literature, attending educational workshops and in-services, consulting, and networking with other healthcare professionals
Participate in department quality improvement and risk management activities by identifying client care issues and collecting data
Participate in research opportunities, as required
Participate in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor as appropriate
Provide input in the development and revision of standards of care, policies, and procedures and advocate for improvements in clinical practice, healthcare, and healthcare services
Participate in the development, implementation, and evaluation of quality improvement initiatives within the program by providing recommendations to the Manager
Perform other related duties, as assigned
Requirements
Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM)
One (1) year recent related clinical experience assessing and treating complex geriatric and/or adult patients with chronic health conditions in an acute or community/outpatient care setting including recent experience in care and discharge planning, or an equivalent combination of education, training, and experience
Valid BC Driver's license and access to a personal vehicle for business-related purposes
Demonstrated knowledge, skills, and competence in areas such as gerontology and adults living with complex frailty and chronic illnesses
Demonstrated ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions
Demonstrated ability to communicate effectively, both verbally and in writing
Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively
Knowledge of broad healthcare services, community resources agencies, and their role in providing a continuum of care
Ability to promote client-focused care including sensitivity to diverse cultures and preferences
Ability to independently manage and prioritize clients with diverse healthcare issues
Ability to teach clients and others about topics essential to healthcare, health promotion, and care self-management using care management principles
Ability to work effectively in a dynamic environment with changing priorities
Ability to work independently and as a member of an interprofessional team
Ability to operate related equipment including applicable software applications
Physical ability to perform the duties of the position
Benefits
Four weeks of vacation to start
Comprehensive health benefits
Pension plan
Increased overall compensation as a regular status nurse
100% employer-paid benefits with no out-of-pocket expenses
Immediate enrollment in a defined pension plan
Eligibility for 87% maternity leave top-up
Flexible scheduling options for regular status nurses
About the Company
Fraser Health is the heart of healthcare for over two million people in Metro Vancouver and the Fraser Valley in British Columbia, Canada, on the traditional, ancestral, and unceded lands of the Coast Salish and Nlaka
’pamux Nations and is home to 32 First Nations within the Fraser Salish region. Its hospital and community-based services are delivered by a team of over 50,000 staff, medical staff, and volunteers. Fraser Health is committed to planetary health and values diversity in the workforce, striving to maintain an environment of respect, caring, and trust.
Canada's first provincial health services authority.
