Community Health Nurse - Licensed Practical Nurse

Detailed Overview

In accordance with the competency guidelines and full scope of practice within the Standards of Practice as outlined by the British Columbia College of Nurses and Midwives (BCCNM) and the Mission and Values of Fraser Health, the Community Health Nurse (CHN) - Licensed Practical 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 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 utilizing the provincial Primary & Community Care model to optimize recovery or adapting to changes in the client's condition to minimize 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 Establishes a therapeutic relationship with the client through the use of 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.

Screens referrals, provides individualized client assessments, interprofessional care planning and interventions including clinical care, when appropriate and referral services for clients with multiple complex chronic conditions; assists clients to achieve an optimal level of function by facilitating timely and appropriate health services and utilizing a variety of resources and services; collaborates with the primary care provider, client, the 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.

Initiates/develops a comprehensive shared client care plan, in collaboration with the interprofessional team, primary care provider, client and/or family, other healthcare providers and/or referring clinics; facilitates and supports the transition of the client care plan to the referring source, primary/community care provider and/or community agencies. Provides direct client care and identifies other care services required in accordance with applicable guidelines, policies and evidence-based best practice;

provides comprehensive explanations of care to the client and family, as appropriate. As required based on the local community model, assigns direct client care tasks to Community Health Workers; provides in-home demonstrations and training to standards of practice for assigned tasks; collaborates with the Community Health Nurse - Registered Nurse in the monitoring of Community Health Workers performing clients specific delegated direct care tasks to ensure that the Community Health Worker has the necessary knowledge, skills and support to perform the task within the clearly defined limits.

Facilitates care conferencing to review client care plan, in collaboration with the interprofessional team and primary care provider to determine timing and referral to other services and/or interventions to improve patient/client outcomes; initiates, monitors and evaluates the appropriateness and effectiveness of the short and long term care plan to meet specific client goals; develops next steps in collaboration with the client and family;

develops and supports a transition process for achieving client care goals across the care continuum including discharge and/or transfer to other services, as required. Discusses clinical findings with client/family, in collaboration with the interprofessional team to develops action plans and sets goals directed at clinical needs, self
-management, self-care and improved health-related quality of life; accesses system information and resources to review client data such as medical history, progress notes, consultation reports, lab reports and incorporates findings into the care plan; plans, organizes and establishes priorities by using resources effectively and efficiently; responds to unanticipated events and/or changing client or service assignment needs, as needed. Supports clients and their families before, during and after interprofessional conferences and clinic visits by providing information through their decision-making process regarding treatment options;

advocates on behalf of the…