Chronic Disease Nurse, Primary Care- Hope / Agassiz / Harrison Hot Springs / Kent

Detailed Overview

• Participates as a member of a multidisciplinary team in the planning, implementation, development and evaluation of individual care plans for clients with chronic disease referred to a Chronic Care Centre;
• supports patient self-management of the chronic disease through teaching and counselling, on a group and individual basis, in order to promote and assist with health lifestyle adjustments;

conducts outpatient assessments, shares information and collaborates with other health care team members in order to ensure the provision of quality chronic disease management services through the health care system.

Responsibilities Develops, implements, revises and evaluates individualized care plans based on established assessment processes, in collaboration with other health care professionals;

assists in the treatment and intervention of the clients to support optimal health care outcomes and clients are able to self manage their chronic conditions.

Enhances client self-management of chronic disease and co-morbidities through various teaching / education methods such as individual counselling and group facilitation;

works with the client to develop and / or modify self-management techniques to adjust to changing conditions in order to achieve optimal health care outcomes.

Writes timely and accurate patient reports of relevant observations including patient and / or family teaching and evaluation of nursing care.

Participates and provides input into clinical case reviews, program development and evaluation, education materials and delivery and other clinical resources.

Provides orientation and mentoring to new staff; participates as a preceptor to students. Provides input into policies, protocols and procedures to meet best practices / standards / protocols for client education on chronic disease management.

Acts as a resource to other health care professionals on chronic diseases and / or management; provides information or in-service sessions to staff on various chronic disease topics including disease management, as required.

Participates in quality improvement and risk management activities by participating in research and special projects related to chronic disease management.

Maintains client records, documentation and related statistics, as required. Participates on local, regional, program and professional committees, as assigned.

Performs 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) and current CPR certification.

Two years' recent related clinical experience treating and assessing patients with chronic diseases within a chronic disease management framework including patient self-management, or an equivalent combination of education, training and experience.

Skills and Abilities Demonstrated knowledge of current standards for chronic disease management Demonstrated understanding of the principles of adult / child / youth learning including strategies around empowerment and motivation Ability to communicate effectively, both verbally and in writing Ability to work independently and as a member of an multidisciplinary team Demonstrated ability to teach and implement a chronic disease education program for patients / clients / families, in both an individual and group setting Ability to create and maintain rapport with the patient / client / family and with other health care providers Ability to plan and prioritize work Ability to operate related equipment included applicable software applications Physical ability to perform the duties of the position