Compensation

$78,577.00 to $108,045.00 Annually based on qualifications and experience.

- Registered Nurse Care Coordinator position is available as either Permanent Full-time (35 hours per week) or Permanent Part time (21 hours per week).

Employment Status

Permanent Full Time

Location:

North Vancouver - Tsleil-Waututh Nation

Department

Health & Community Services

Hours Per Week

35 Hours per week

Compensation

$78,577.00 to $108,045.00 Annually based on qualifications and experience.

- Registered Nurse Care Coordinator position is available as either Permanent Full-time (35 hours per week) or Permanent Part-Time (21 hours per week).

About Us

ćećəwət leləm “Helping House” provides wholistic, culturally integrated health & wellness services for Indigenous clients and families. Our interdisciplinary teams include community health programming; primary care services; home care services; peer support, harm reduction, and crisis response; integrative therapy; wholistic wellness; and Indigenous Elders, Healers, and Knowledge Keepers. Together, we strive to support Tsleil-Waututh Nation members and families through care that is trauma-informed, relationship-centered, and guided by the Nation’s teachings on balance and interconnectedness.

Job Summary

Reporting to the Health and Wellness Director, the RN Care Coordinator is responsible for supporting clients in developing, maintaining, and/or regaining their sense of wellbeing and independence at home and in the community.

Duties And Responsibilities

Providing Home Care Nursing Services:

- Using a trauma-informed approach, promotes a culturally secure and therapeutic care environment in support of client self-advocacy and self-determination




- Performs comprehensive environmental assessment of the home, along with a thorough evaluation of client’s physical, cognitive, and psychosocial functioning to identify barriers to health
- Provides home care nursing assessment and nursing care throughout the adult and older adult health trajectory, including chronic disease management, wound care therapy, and end-of-life palliative assessment and nursing care
- Upon identifying client goals and needs, tailors individualized care plans in consultation with clients, their families, and members of the interdisciplinary team, providing joint home visits with other team members as needed
- Implements evidence-informed interventions that respect self-determination, strengthen self-management, and bolster engagement in meaningful activities, while supporting family and caregiver capacity
- Maintains accurate documentation and reporting of outcome measures consistent with TWN policy and professional standards of practice
- Using a trauma-informed approach, promotes a culturally safe and therapeutic care workplace in support of client self-advocacy and self-determination

Care Coordination & Caseload Management

- With cultural sensitivity and humility, fosters care relationships with clients and their self-identified families and support persons to help establish rapport, trust,



and mutual respect
- Assesses client’s health and functional status, along with their informal support network, and bolsters integrity of supports as needed, by way of advocacy, shared care planning, and integration of additional formal supports and resources
- Promotes client independence, participation, and wellness by using a care coordination process of client assessment, care planning, implementation, and ongoing evaluation and re‑assessment as needed
- Provides direction to home support staff by creating client-specific home support service plans which delegate home support service tasks in support of client independence with their iADLs and ADLs
- Monitors and evaluates both clinical care plans and home support service plans to ensure optimal and effective care delivery
- Initiates and participates in care conferences with clients, families, interprofessional team members, and service providers to help ensure a coordinated and integrated approach to client care
- Supports clients’ access to health services and helps clients and families navigate resources and overcome personal and systemic barriers to accessing care and achieving health & wellness
- Effectively consult and confer with various team members in support of interdisciplinary collaboration and shared care planning

Supporting Continuity Of Care

- Anticipates medical and functional changes over time, especially in the context of serious illness or chronic disease and provides avenues for early engagement and conversations with clients and families to ensure care planning is guided by clients’ and families’ goals, wishes, a

📌 Registered Nurse Care Coordinator (North Vancouver)
🏢 səlilwətaɬ (Tsleil-Waututh Nation)
📍 North Vancouver