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Detailed Overview In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice, the vision, mission and values of Fraser Health and the Langley Specialized Seniors Team Program, and working collaboratively and in partnership with the interprofessional care team and physicians in the provision of person-centred care, the Registered Nurse assesses, plans, provides and evaluates geriatric nursing care and teaches clients and caregivers about geriatric health issues and illness management, prevention and treatment in the home or community setting. Responsibilities Accepts referrals to the Langley Specialized Seniors Team and provides geriatric nursing services to clients in their homes, community and/or mobile clinic setting by assessing physical, emotional and psychosocial needs of the client and their caregivers. Collects information from a variety of sources using skills of observation, communication, data review, and physical assessment. Makes a nursing diagnosis of the client's condition and determines whether the condition can be improved or resolved by an appropriate nursing intervention. Develops a comprehensive care plan in collaboration with the interdisciplinary care team and in partnership with the client's physician. Facilitates, supports and communicates the care plan according to established protocols. Follows up with clients and/or caregivers, physicians and other health care providers regarding complex geriatric medical conditions through client reassessment and the sharing of medical information. Coordinates home care services by liaising with other Home Health staff and community agencies. Teaches clients and caregivers about geriatric health issues, care plans, the roll of the Langley Specialized Seniors Team Program in illness prevention, health restoration and health maintenance to help clients accomplish their health care goals. Assesses learning needs of the client and caregiver; provides information and demonstrates care activities that supports self-care consistent with the care plan. Collaborates with members of the interprofessional care team including physicians in the identification and resolution of issues, adjustments to care plans, and in regard to changes in patient condition. Plans and discusses referral information and available community resources with client and their caregivers and, in collaboration with members of the interprofessional care team, initiaties referrals to appropriate health care/community agencies. Documents assessments, nursing diagnosis, observations, interventions, client/caregiver responses, outcomes/evaluations, and referrals according to practice standards and Fraser Health procedures. Participates in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor as appropriate. Participates in research and quality improvement activities by identifying client care issues, collecting data, and identifying needs and recommendations for corrective action and changes to practices, procedures or protocols. Provides feedback to the Manager/delegate regarding the effectiveness of the Langley Specialized Seniors Team Program , policy/clinical decision support tools (e.g. clinical pathways, standards, order sets and procedures), and equipment. Performs other related duties as required. Qualifications Education and Experience Graduation from an approved school of Nursing with current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Two years recent, related nursing care experience working with the geriatric population, or an equivalent combination of education, training and experience. Valid BC Driver's License and access to a personal vehicle for business related purposes. Skills and Abilities Ability to complete initial and ongoing client assessment (clinical and diagnostic reasoning), specific to the geriatric client and provide nursing care through appropriate/prescribed technical, therapeutic, safety type interventions in home/community/mobile clinic setting. Ability to collaborate and partner with members of the interprofessional care team and physicians. Ability to communicate effectively with clients, caregivers, the public, medical staff and members of the interprofessional care team using verbal, written and electronic communication means. Ability to promote person-centred care that demonstrates empathy for clients and caregivers, sensitivity to diverse cultures and preferences, and patient advocacy. Ability to integrate and evaluate data from multiple sources to problem-solve effectively. Ability to teach and instruct clients and caregivers about topics unique to the geriatric population that is essential to their health care and well-being. Ability to organize and prioritize work. Ability to operate related equipment including relevant computer applications. Physical ability to perform the duties of the position.