Chronic Disease Nurse, Primary Care - Hope

City Hope / Agassiz / Harrison Hot Springs / Kent
Job ID 2023-41903
Nursing - (RN) - Primary Care
Posting Date
3 months ago(3/8/2023 1:53 PM)
Employment Type
Full Time
Scheduled Start & Stop Times
0800 - 1600
Days Off
Saturday, Sunday
Primary Care & Community Health Networks
Salary at Time of Posting
$36.23 - $47.58 / hour

Why Fraser Health?

Fraser Health is responsible for the delivery of hospital and community-based health services from Burnaby to Fraser Canyon on the traditional, ancestral and unceded territories of the Coast Salish and Nlaka’pamux Nations, and is home to six Métis Chartered Communities.


Our team of 45,000 staff, medical staff and volunteers is dedicated to serving our patients, families and communities to deliver on our vision: Better health, best in health care. Learn more.


Come work with us!


Fraser Health is proudly recognized as a BC Top Employer. Joining our team offers you opportunities to work in a rapidly growing organization with health professionals who are excellent in their respective fields, career growth and advancement, a competitive compensation package (including four weeks of vacation to start, comprehensive health benefits, and pension plan), and the rewarding opportunity to make a difference every single day in health care.


Effective October 26, 2021 all staff for all positions across health care in British Columbia are required to be fully vaccinated against COVID-19 (have received a full series of a World Health Organization “WHO” approved vaccine against infection by SARS-COV-2, or a combination of approved WHO vaccines). Please note this applies to all postings, and there are no exceptions.


Fraser Health values diversity in the work force and strives to maintain an environment of Respect, Caring and Trust. Fraser Health’s hiring practices aspire to ensure all individuals are treated in an inclusive, equitable, and culturally safe manner.


Connect with us!


Connect with us on our Careers social channels where you’ll learn about exciting opportunities, get career tips from our recruiters, and meet some of your future team members! You can also visit us on Indeed and Glassdoor.


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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.


  1. 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.
  2. 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.
  3. Writes timely and accurate patient reports of relevant observations including patient and/or family teaching and evaluation of nursing care.
  4. Participates and provides input into clinical case reviews, program development and evaluation, education materials and delivery and other clinical resources.
  5. Provides orientation and mentoring to new staff; participates as a preceptor to students.
  6. Provides input into policies, protocols and procedures to meet best practices/standards/protocols for client education on chronic disease management.
  7. 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.
  8. Participates in quality improvement and risk management activities by participating in research and special projects related to chronic disease management.
  9. Maintains client records, documentation and related statistics, as required.
  10. Participates on local, regional, program and professional committees, as assigned.
  11. Performs other related duties as assigned.


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 (2) 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


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