Permanent PT Community Outreach Nurse, Maple Ridge ICM Team

POSITION TITLE: Community Outreach Nurse
PROGRAM: Maple Ridge ICM Team
SALARY: $36.23-$47.58 (BCNU Level 3 RN/RPN)
TYPE: Permanent Part Time, 0.44 FTE
SCHEDULE: Monday, Wednesday, Friday 9:00am-3:00pm;
START DATE: As soon as possible

To apply please include your resume, with a cover letter describing your suitability for this position, in an email with the subject line of “job2021.264” to: Shawn Currell, Assistant Program Manager at the Maple Ridge ICM Team, at


RainCity Housing is an organization that makes a difference in people’s lives. With a goal of providing a home for everyone, RainCity’s programs sustain relationships, strengthen communities and make change for people experiencing homelessness and mental health, trauma and substance use issues. We invite you to be a part of the change.


RainCity Housing serves a diverse group of people and we need a staff group that reflects the diversity. People of diverse backgrounds and cultures are encouraged to apply.


Reporting to the Team Leader or designate, the Community Outreach Nurse assesses, identifies, plans, implements and evaluates the nursing care required to assist ICM team clients in meeting their physical, social, spiritual and psychological needs. The Nurse works within the team’s interdisciplinary clinical framework to provide client centered and strengths based care in accordance with the CRNBC/CRPNBC Standards of Practice and consistent with the mission, vision and values and established policy and protocols of RainCity Housing and the ICM team. The Nurse provides treatment services that are both inclusionary and flexible for individuals with mental illness, addictions and/or chronic medical conditions and ensures integration and continuity across the care continuum. The Nurse establishes and maintains relationships with, and consults with, service and housing providers, clients, their families and colleagues to provide appropriate treatment services based on best practices and client need. The Nurse performs duties such as, intake, mental and physical health and addictions assessment, treatment planning, crisis intervention, consultation, and individual counseling.

The Nurse also performs Service Coordination, maintaining oversight to ensure that client’s self-identified goals for recovery and community integration are supported by appropriate services and practices, consistent with the values of self-determination/choice and harm reduction. Working in collaboration with the other members of the ICM team, the Nurse coordinates the provision of ICM services for clients served by the team members in their area of specialization. Services are provided in any environment including:  the streets, shelters, hospitals, apartments, and the office.


Maple Ridge ICM – Intensive case management plays a vital role in the continuum of services and supports for people with serious mental illness and substance use issues in BC. The ICM Team assists clients by helping them to identify and achieve personalized recovery goals and by assisting in the coordination of support services (e.g. mental health, criminal justice, family, and addictions services). The ICM team also provides housing opportunities for clients using a ‘housing first’ scattered site approach. Clients are offered immediate access to rent supplements so they have the opportunity to live in the same kinds of permanent independent apartments that are typically available to people without mental illness, and the rent supplements are provided without requiring participation in psychiatric or substance use treatment. Self-determination and choice are at the centre of all considerations with respect to the provision of housing and support services.



  1. Assesses, plans, implements and evaluates mental and physical health nursing care for patients/residents using a framework for nursing practice.
  2. Develops, implements, evaluates and revises individual mental and physical health nursing care plans through methods such as assessing clients problems and needs, planning and prioritizing nursing interventions, implementing interventions and reassessing if goals are not met and modifying plan of care based on evaluation.
  3. Reviews client’s mental and physical health status through methods such as reviewing the client’s chart and other written information, client observation, collateral information and consultation with the client, ICM team members and other members of the client’s formal and informal support network.
  4. Provides nursing care according to identified policies and procedures, technology and ICM program standards and evaluates outcomes, records observations and reports problems and/or changes to designated staff. Administer medications to clients.
  5. Identifies client and family learning needs and incorporates teaching and counseling into the care plan and nursing interventions and/or makes referrals to other identified resources.
  6. Provides direct nursing interventions for management of crisis and life threatening situations.
  7. Documents information including assessments, nursing care plans, patient/resident status and progress and discharge plans in a manual and/or computerized environment.
  8. Participates in nursing orientation and shares clinical knowledge with other nursing staff, nursing students and other members of the ICM team.
  9. Participation in an afterhours on-call rotation.
  10. Performs other related duties as assigned.


  1. Establish a dignifying and purposeful relationship with the client, contacting and getting to know the client as a unique individual, and clarifying the role of the Service Coordinator and client in the service planning process.
  2. Collaborate with client and the ACT team in the development of a comprehensive strengths-based service plan that is reviewed and modified with the client on a regular basis; ensure that the client’s self-identified goals are supported by the ICM team and other relevant services.
  3. Provide, coordinate and monitor services to clients to ensure the client is receiving individualised services in the following areas: housing (including landlord supports), school, training & work opportunities, activities of daily living, health, illness self-management, relapse prevention, money management, advocacy for benefits and access to services, medication support, problem solving, family life & social relationships, nutrition, recreational and leisure activities, transitions between hospital and the community.
  4. Assist the client in self-managing all aspects of their life, including their mental illness, substance use and other health conditions by such methods as information and education, coaching, practical problem-solving, and linkages with peer supports, and consumer advocacy groups.
  5. Coordinate and monitor referrals to community services and advocate for client rights re: dignity, access, self-determination, privacy, access to information; as required, initiate and/or participate in case conferences that include the client, family, other informal supports and service providers to ensure coordination of care and resolution of emergent issues.
  6. Provide supports for crisis intervention and prevention by identifying potential crises and implementing preventative plans, responding to crises as they arise (mental health, physical health, non-violent crisis intervention, housing), report all crises to the Team Leader, using critical incident forms as required.
  7. Provide supports related to housing including completing paperwork related to tenancy, assisting in packing and transporting belongings and furniture and setting up household, and coaching on landlord relationship, cleaning, and orienting to and connecting with the local community.
  8. Actively participate in building a skilled, cohesive, collaborative staff team, by methods such as demonstrating commitment to program values and principles, resolving conflict and negativity as they arise, assisting in orienting, training and mentoring of all staff, including casuals.
  9. As a member of the ICM Team, engage in on-going program planning, development, evaluation and quality improvement activities that facilitate team goal setting, problem solving, conflict resolution and collaboration by methods such attending meetings and reviewing team policies, procedures, and communications systems.
  10. Prepare and maintain written and computerized records, compile reports and complete other program documentation, including writing and updating service plans for primary caseload, writing progress notes, completing incident reports, on-call logs, letters, and documentation related to the research project.
  11. Participate in afterhours on-call rotation.
  12. Perform related work as assigned


Education and Experience

  • Baccalaureate in Nursing or Health Sciences or Psychiatric Nursing.
  • Current practicing registration with the College of Registered Nurses of British Columbia (CRNBC) or the College of Registered Psychiatric Nurses of British Columbia (CRPNBC).
  • Three (3) years’ recent related experience providing treatment services to individuals with mental health, addiction and chronic medical concerns,
  • Or an equivalent combination of education, training and experience.
  • Valid class 5 BC Driver’s License and acceptable drivers abstract and full time use of a reliable vehicle

Knowledge and Abilities

  • Broad knowledge of nursing theory and practice within a client and family centred model
  • Broad knowledge of CRNABC or CRPNBC standards for nursing/psychiatric nursing practice.
  • Broad knowledge of diagnoses, treatment and support resources in the areas of mental illness, substance use, physical health, including HIV and Hepatitis C.
  • Broad knowledge of psychopharmacology
  • Broad knowledge of the principles of recovery in mental illness and problematic substance use.
  • Knowledge of harm reduction principles and activities
  • Knowledge of counseling skills, including motivational interviewing
  • Knowledge of other health care disciplines and their role in client care.
  • Basic knowledge of legislation and government policies and procedures that relate to client, including the Residential Tenancy Act and the BC Mental Health Act.
  • Demonstrated understanding of oppression and marginalization, specifically as related to people with experience of a mental illness, addiction, or homelessness.
  • Ability to work with individuals from diverse backgrounds and be flexible and creative in providing services
  • Ability to identify and work to increase client strengths, including the use of hope inducing strategies and assisting the client in self-managing their illness and other aspects of their life.
  • Ability to commit to service partnerships and build relationships by providing assistance and support.
  • Ability to effectively and safely resolve crisis situations
  • Ability to apply knowledge of theory and practice to a case management process.
  • Ability to communicate effectively, both orally and in writing.
  • Listening and information seeking skills that promotes communication and lead to a co-operative approach to problematic client actions and choices, and problem solving within a multidisciplinary setting.
  • Ability to work both independently and collaboratively as a member of a multidisciplinary team.
  • Ability to establish workload priorities, adjust to new or unexpected events, problem solve, and deal effectively with conflict situations.
  • Ability to provide consultation and leadership to other ICM team members.
  • Ability to operate a computerized client care information system and word processing, spreadsheet, Internet and e-mail software, and smartphone, and related equipment.
  • Physical ability to perform the duties of the position such as, but not limited to working in all-weather conditions, sitting/driving for long periods, assisting with packing and moving household items, lifting/carrying items up to 30lbs, climbing stairs.