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Fraser Health

Public health authority operating hospitals

Community Health Nurse

Nursing & Frontline Patient CareConfirmed live in the last 24 hours
Full-timeMaple Ridge, BC, CanadaCA$41.42 - CA$59.52 /hr

About the Job

Requirements

  • Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives.
  • One year of 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.
  • A valid British Columbia driver's license and access to a personal vehicle for business-related purposes.
  • Demonstrated knowledge, skills and competence in gerontology and adults living with complex frailty and chronic illnesses.
  • Ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions.
  • Ability to communicate effectively, both verbally and in writing.
  • Ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively.
  • Knowledge of broad health care services, community resource 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 health care, 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.

Responsibilities

  • Establish a therapeutic relationship with clients using interpersonal and interviewing techniques, in person and/or by telephone, to support client choice, autonomy in decision-making and care planning, dignity, and privacy.
  • Screen referrals, provide individualized client assessments, interprofessional care planning and interventions, including clinical care when appropriate, and referral services for clients with multiple complex chronic conditions; facilitate timely and appropriate health services and use available resources to help clients achieve optimal function; collaborate with primary care providers, clients, families, supports, caregivers, health professionals, clinics, hospitals, and community resources to identify and resolve care issues and coordinate integrated care and services.
  • Develop comprehensive shared patient/client care plans with the interprofessional team, primary care provider, client and/or family, other health care providers, and referring clinics; facilitate and support transitions of the care plan to the referring source, primary/community care provider, and/or community agencies.
  • Provide direct client care and identify other required care services in accordance with applicable guidelines, policies, and evidence-based best practice; explain care comprehensively to clients and families as appropriate.
  • As required by the local community model, make decisions about client-specific direct-care tasks; assign tasks to Community Health Workers and, when appropriate, delegate client-specific direct-care tasks; provide in-home demonstrations and training to standards of practice; ensure Community Health Workers have the knowledge, skills, and support to perform delegated tasks within defined limits; collaborate with the Community Health Nurse—Licensed Practical Nurse in monitoring Community Health Workers performing delegated tasks.
  • Facilitate care conferences with the interprofessional team and primary care provider to review care plans and determine timing and referrals to other services or interventions; initiate, monitor, and evaluate the appropriateness and effectiveness of short- and long-term care plans; develop next steps with clients and families; support transitions toward client care goals across the continuum, including discharge and/or transfer to other services.
  • Discuss clinical findings with clients and families, in collaboration with the interprofessional team, to develop action plans and goals addressing clinical needs, self-management, self-care, and health-related quality of life; access system information and review client data, including medical histories, progress notes, consultation reports, and laboratory reports, and incorporate findings into care plans; prioritize and use resources effectively and efficiently; respond to unanticipated events and changing client or service-assignment needs.
  • Support clients and families before, during, and after interprofessional conferences and clinic visits by providing information about treatment options; advocate for client and family choices and needs; provide direct care in clinics, the community, or the home as clients transition to another program, service, or health care provider.
  • Arrange and participate in joint home visits with clients and/or families and other health professionals as required; advise clients and caregivers about available community resources.
  • Provide health counseling, education, self-management, self-monitoring, and wellness, health-promotion, and prevention support through clinic, telephone, or home visits; collaborate with health professionals in clinics, community programs, and services to facilitate information flow across settings in the primary and community care network.
  • Maintain clinical records, including intake screens, client assessments, clinical interventions, treatment formulations, care plans, and progress notes; maintain client statistical information in accordance with established policies, standards, and procedures.
  • Maintain professional practice growth, knowledge, and expertise in line with current standards by reviewing relevant literature, attending educational workshops and in-services, consulting, and networking with health professionals.
  • Participate in departmental quality-improvement and risk-management activities by identifying client-care issues and collecting data; participate in research opportunities as required.
  • Participate in nursing staff and student orientation and ongoing education by providing information and acting as a preceptor as appropriate.
  • Provide input into developing and revising standards of care, policies, and procedures, and advocate for improvements in clinical practice, health care, and health care services; participate in developing, implementing, and evaluating program quality-improvement initiatives by providing recommendations to the Manager.
  • Perform other related duties as assigned.

About the Company

Fraser Health

Public health authority operating hospitals

Fraser Health is a Canadian health authority that provides health services to about 1.8 million people in British Columbia. It operates 12 hospitals, including major trauma centers, as well as outpatient care and surgery centers, and offers services in residential care, public health, home health, and mental health. It employs more than 40,000 staff, medical staff, and volunteers who coordinate care across hospitals, clinics, and community settings to ensure patients receive the right care at the right time. Its goal is to keep communities healthy by delivering accessible, high-quality care and by creating good workplaces for its employees and volunteers.

Company size
10,001+
Company stage
Grant
Total funding
$20K
Headquarters
Surrey, Canada
Founded
2001

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