Complex Care Clinician, Home Health

Please note that the internal competition for this position is now closed, however we are still accepting late applications from qualified internal candidates. Should you choose to apply, your application will only be considered after on-time internal applicants have been considered. minimum Nurse to Patient Ratios (mNPRs) Vancouver Coastal Health (VCH) is proud to be part of the provincial implementation of minimum Nurse to Patient Ratios (mNPRs), an initiative aimed at enhancing nursing practice and strengthening quality of care across the health system. mNPRs set the minimum number of nurses providing care to patients on a given unit. In British Columbia, mNPRs are developed in partnership with the Ministry of Health, the BC Nurses’ Union (BCNU) and health organizations.

Guided by our values: We Care for Everyone, We Are Always Learning and We Strive for Better Results, we remain committed to fostering quality practice and learning environments where nurses can grow and thrive.

Description

JOB

SUMMARY:Within a comprehensive care coordination model and within the context of a client and family centered care model, working across multiple sites/clinics/services (if applicable), applies specialized theory, clinical expertise and knowledge relating to designated/specific client populations. Provides wrap-around care to designated client populations, with a strong commitment to client and family-centered care. Leverages clinical expertise and knowledge, to address the complex medical, cognitive, and behavioral needs of eligible clients, primarily focusing on delivering safe, ethical, and high-quality care. Ensures that each client's care plan is tailored to their specific needs and goals, actively integrating principles of prevention, chronic disease management, palliative approach to care, and self-care management as needed. Performs ongoing assessments that allow for the identification of any issues or deviations from the care plan, prompting collaboration with appropriate medical providers, care providers, interdisciplinary team members, and community agencies to address these concerns. Through active collaboration with interdisciplinary team members, the leadership team, and other healthcare professionals/providers, strives to enhance the overall quality of life and consistently achieves excellence in client and family-centered care. By maintaining a strong dedication to individualized and comprehensive care, contributes significantly to the overall well-being and positive outcomes of the clients they serve.Practices within the context of a client and family centered care model and in accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice for registered nurses and registered psychiatric nurses. Practices within the scope of practice and code of ethics set by the organization as per VCH policies and guidelines/clinical practice documents and within own competence. Practices in alignment with the vision, mission, goals and values of the organization as well as with the concept of a client and family centered care model. This work is framed within VCH’s commitments to our pillars of Indigenous Cultural Safety, Anti-Racism, Equity, Diversity and Inclusion, and Planetary Health.QUALIFICATIONS:Education & Experience Current practicing registration as a Registered Nurse or Registered Psychiatric Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Two years’ recent case management or home care nursing experience, including experience working with the complex medically frail population or an equivalent combination of education, training and experience. Local area travel requires the use of personal vehicle. Valid BC Driver’s License.Knowledge, Skills & AbilitiesDemonstrated knowledge and ability in nursing practice related to designated client group –

Home

Health

Preventative

Complex

Care clients:

Demonstrated proficiency in performing comprehensive, evidence informed and strength-based holistic health assessment and evaluating health promotion activities, using multiple sources and methods to identify needs, assets, inequities and resources.

Knowledge of appropriate assessment and screening tools used to support decision making in management of complex client’s care needs (e .g. risk assessment tools, Inter-RAI, ethical decision tools, Zarit tool, MMSE etc.).

Demonstrated proficiency in performing focused assessments, elicit, synthesize and integrate all relevant information from a variety of sources and develop client-centered plan of care using evidence-informed and best practice in the provision of safe, quality care.

Demonstrated ability to use critical thinking and clinical judgement to take action and prioritize care when unexpected changes occur (e.g. changes in acuity and stability, emergent health needs and functional decline).

Ability to engage clients and individuals involved in client’s circle of care to actively participate as equal partners in care planning, decision making and care delivery evaluation.

Demonstrated competency in ongoing monitoring, evaluating and adjusting client’s care plan based on effectiveness of interventions and/or changes in condition or environment. Modifies client’s care plan in collaboration with the medical provider, the client and the individuals involved in client’s circle of care.

Knowledge of effective strategies for connecting with clients and individuals involved in client’s circle of care to promote collaborative, active and informed shared decision-making while taking into account the determinants of health.

Demonstrated ability to organize and facilitate meetings and collaboration with clients and individuals involved in client’s circle of care to enhance client-centered care (i.e. leads case conference with most responsible provider).

Demonstrated competencies in basic and advanced nursing skills to deliver nursing interventions as per entry- level competencies and home health competencies for registered nurses and registered psychiatric nurses (e.g. medication administration, wound care, vital signs, pain management, setting up home support or delegation of tasks etc.).

Demonstrated knowledge of acute and chronic disease management, life limiting diseases, palliative care, mental health and substance use and appropriate assessment tools and interventions to support self-management to optimize mental and physical health.

Demonstrated skill in conducting goals of care conversations and in understanding the care goals and what is most important to the client.

Demonstrated ability to provide culturally safe care to diverse populations, including Indigenous People in accordance with BCCNM practice standards for Indigenous Cultural Safety, Cultural Humility, and Anti-Racism.

Demonstrated understanding of Trauma Informed Practice and Harm Reduction.

Knowledge of provincial acts, regulations, and program policies and guidelines related to home, community and primary care.

Demonstrated skill in performing RN/RPN autonomous scope of practice and standards of care relevant to designated patient/client population.

Demonstrated skill in CPR techniques.The hours of work including days off and work area may be subject to change consistent with operational requirements and the provision of the Collective Agreement and applicable statutes. Details At Vancouver Coastal Health, our vision of healthy lives in healthy communities inspires us and our values and pillars guide us. We support equitable practices, diverse teams and inclusive environments, which are vital to creating welcoming spaces where everyone can bring their whole selves to work and feel supported. We encourage applications from equity-deserving communities, including Indigenous Peoples and members of racialized groups, people with disabilities and people of all gender identities and expressions and sexual orientation.Vancouver Coastal Health is proud to be recognized as one of Canada’s Top 100 Employers, BC’s Top Employers, Canada’s Best Diversity Employers and Canada's Top Employers for Young People in 2026.Unless otherwise noted on the posting, internal job postings close at 8:00 AM Pacific Time on the listed Closing Date. Please submit your digital application via the Internal Career Portal prior to the Closing Date & Time.Nursing & LPN successful applicants will be notified by email.We regret that only short listed candidates will be acknowledged.This is an internal job posting for Vancouver Coastal Health employees only.