Salary
The salary range for this position is CAD $41.42 - $59.52 / hour

Job Summary
Joining our team offers you opportunities to work in a rapidly growing organization with health professionals who are excellent in their respective fields, career growth and advancement, a competitive compensation package (including four weeks of vacation to start, comprehensive health benefits, and pension plan), and the rewarding opportunity to make a difference every single day in health care.

Have you heard about the new incentives within the new provincial collective agreement for Nurses that make taking a regular/temporary position much more appealing? The details below outline a few of the perks that would be available to you, take a read through and see why it’s worth it.

Your overall compensation is increased – as part of the new provincial collective agreement, as a regular status nurse, you receive an increase to overall compensation.

100% of your advantages are employer‑paid with no out‑of‑pocket (i.e., no waiting for reimbursement).

You’re immediately enrolled in a defined pension plan (no waiting period).

You’re eligible for 87% maternity leave top‑up.

You can maintain a flexible schedule – as part of the new collective agreement, there are more flexible scheduling options available for regular status nurses.

Detailed 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. The CHN 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. The role 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 utilizing the provincial Primary & Community Care model to optimise recovery or adapt to changes in the client’s condition to minimise avoidable admissions 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 interviewing techniques, in person and/or over the telephone, to ensure the client’s choice and autonomy in decision‑making and care planning, including the client’s right to dignity and privacy.

Screen referrals, provide individualized client assessments, interprofessional care planning and interventions including clinical care where 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 health care 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 where appropriate.

When 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, where appropriate, delegate client‑specific 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 required 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 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; 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 where 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 where required.

Participate in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor where 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 programme by providing recommendations to the Manager.

Perform other related duties as assigned.

Qualifications
Education and Experience

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.

Skills and Abilities

Demonstrated knowledge, skills and competence in 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 health‑care issues.

Ability to teach clients and others about essential health care topics, 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.

About Fraser Health
Fraser Health is the heart of health care 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.
People – those we care for and those who care for them – are at the heart of everything we do. Our hospital and community‑based services are delivered by a team of 50,000+ staff, medical staff and volunteers. We are committed to planetary health and value diversity in the workforce. We strive 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 safe manner.
Together, we are the heart of health care.

Important Notice
Recruitment scam warning: Please be on alert for recruitment scams. Fraser Health is aware of several scams targeting individuals by falsely claiming to represent Fraser Health. We will never ask for money or payment, nor ask you to download or install an app at any point during our recruitment process.

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📌 Community Health Nurse - Registered Nurse - Abbotsford Home Health (British Columbia)
🏢 Fraser Health Authority
📍 British Columbia