1. Carries out health, psychosocial and functional/environmental assessments; identifies strengths, risks, needs and goals in collaboration with client/family/health care team; develops a plan to meet these goals and promote stability in client/family situation; monitors and evaluates effectiveness of plan on an ongoing basis and implements adaptations as necessary.


2. Maintains responsibility and accountability for approving and facilitating access to regionally funded health resources (home support services, adult day programs, residential care) as part of the overall plan.


3. Uses knowledge and skill in area of professional practice, clinical geriatrics and case management theory to independently manage a complex case load; participates in education programs and continually evaluates and develops own competencies and abilities to maintain and improve standards.


4. Facilitates client's transitions through a variety of settings in the health system.


5. Facilitates, provides leadership to and collaborates in interdisciplinary client/family conferences.


6. Advocates on behalf of clients and families to access system information and resources; promotes client's right to autonomy, dignity and privacy; advocates for system/program change that will broaden services and enhance the systems capacity to support clients/families.


7. Mentors and orients new staff, students and other health professionals as requested; represents Home Health by providing public information and education.


8. Maintains related records, documentation and statistics; prepares reports in accordance with established standards and procedures, as required.


9. Participates in local, regional and external committees and working groups to strengthen professional practice, team development, and provides input into operational issues.


10. Performs other related duties as assigned.

Bachelor's degree in Nursing from an approved school of Nursing, plus two (2) years' recent, related nursing experience working with complex geriatric clients and adults with chronic and acute illness, or an equivalent combination of education, training and experience.

Current practicing registration with the College of Registered Nurses' of British Columbia (CRNBC).

Current BC Driver's License and access to personal vehicle for business-related purposes.

• Demonstrated knowledge of gerontology, geriatrics and the needs of adults living with chronic illness.


• Knowledge of the broad health system, community resources and volunteer agencies and their roles and responsibilities in providing a continuum of care.


• Knowledge of chronic disease management models


• Demonstrated ability to apply knowledge of theory and practice to the case management process.


• Demonstrated ability to independently manage and prioritize caseload/workload, and make decision regarding interventions and access subsidized resources.


• Demonstrated ability to develop and implement a comprehensive plan of care


• Knowledge of relevant legislation, standards and policies


• Ability to communicate effectively both verbally and in writing.


• Ability to deal effectively with others


• Ability to organize and prioritize work


• Demonstrated ability to operate related equipment.


• Physical ability to perform the duties of the position