Salary

CAD $41.42–$59.52 / hour

Benefits

- Increased overall compensation as part of the new provincial collective agreement for regular status nurses.
- 100% of perks employer‑paid with no out‑of‑pocket expenses.
- Immediate enrollment in a defined pension plan with no waiting period.
- 87% maternity leave top‑up.
- Flexible scheduling options available for regular status nurses.
- Four weeks of vacation to start, comprehensive health benefits, and a pension plan.

Overview

In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice and the Mission and Values of Fraser Health, the Community Health Nurse (CHN) – Registered Nurse works independently in the community setting. Works collaboratively and as a member of an interprofessional team in the management of an assigned client caseload including assessments, coaching, interventions, client care services and follow‑up to enable clients and their families to live confidently and safely at home and/or in the community; emphasizes the promotion, maintenance and restoration of health such as the treatment of chronic diseases through teaching, counselling and direct client care; facilitates and manages client transitions across the healthcare continuum utilising the provincial Primary & Community Care model to optimise recovery or adapt to changes in the client’s condition to minimise avoidable admission to residential and/or acute care facilities; collaborates and ensures linkages with acute, primary and community care healthcare providers including the client’s primary care provider (Nurse Practitioner, Physician, other specialist(s)) and family/supports regarding client care planning; supports clients and families, as client care is transitioned to primary/community care provider including FH and non‑FH community services.

Responsibilities

- Establish a therapeutic relationship with the client through interpersonal and interview techniques, in person and/or over the telephone, to ensure the client’s choice and autonomy in decision‑making and care planning, including respect for the client’s right to 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; assist clients to achieve an optimal level of function by facilitating timely and appropriate health services and utilising a variety of resources and services; collaborate with the primary care provider, client, family/supports/caregivers, other health care 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.




- As required based on the local community model, 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 the clearly defined limits; collaborate with the Community Health Nurse – Licensed Practical Nurse in the monitoring of Community Health Workers performing clients‑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; 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, lab reports and incorporate findings into the care plan; plan, organise 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 client within the clinic/community/home as they transition to another programme, 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 counselling 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 programmes 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 health‑care 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, health care and health care 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.

Qualifications

Education and Experience

Current practising 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 licence and access to a personal vehicle for business‑related purposes.

Skills and Abilities

- Demonstrated knowledge, skills and competence in the 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 health‑care 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 prioritise 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.

Diversity & Inclusion

Fraser Health values diversity in the workforce and strives to maintain an environment of respect, caring and trust. Fraser Health’s hiring practices aspire to ensure all individuals are treated in an inclusive, equitable, and culturally secure manner.

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📌 Community Health Nurse - Registered Nurse- Abbotsford Home Health
🏢 Fraser Health Authority
📍 Abbotsford