Community Wellness Nurse - Elders Living At Home Program (20 hrs, Days)
Boston Medical Center
Nursing Program Coordinator Job in North Plymouth, MA
The Community Wellness Nurse works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. This individual will work collaboratively with and guide a Community Wellness Advocate in completion of assigned patient care related tasks. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure, etc.), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.
Community Wellness Nurse
Department: Elders Living at Home
Schedule: Part Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
Ability to execute core care management duties:
Comprehensive assessment: bio-psycho-social-spiritual
Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
Implementation of care plan;
Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies.
Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital
Meet the patient where he/she is; observe the patient without intervention or judgment
Has knowledge of common chronic medical conditions presented in the population served and is able to:
Educate the patient on their medication conditions and medications, and build their self-management skills;
Use motivational interviewing to promote behavioral change;
Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
Meets regularly with staff at the local Wellness site, such as Property Management Staff, Resident Service Coordinator, and other appropriate staff to triage program issues appropriately.
Facilitates interdisciplinary consultation on patient's behalf through participation in team meetings and clinical reviews
Complies with established metrics for performance and adheres to documentation and work flow standards
Maintains HIPAA standards and confidentiality of protected health information.
Adheres to departmental/organizational policies and procedures.
Community Wellness Nurse will work half-time at the Wellness site
Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process.
Schedules and completes initial community-based visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified timeframes.
Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Clearly documents all activities in the patient's record and care management system.
Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls.
Works with patients and providers to set goals for patient's care and provides guidance for patient to achieve those goals.
Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.
Presents patients at case review meetings succinctly and logically. Consults with Patient Care Manager, primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
Records and monitors the participants' progress toward goals within specific timeframes. Documents assessments and key patient updates; documents relevant day-to-day activities and patient data.
Prepares reports and documents as needed or requested.
NOTE: The Community Wellness Nurse will not provide hands on care or other services noted as home health services, including but not limited to: performance assessments, provision of care, treatment, or counseling; and/or monitoring of patient's health status.
ED and inpatient visits
Total medical expense
Other duties as assigned
AD or BS in Nursing
BS or Masters in Nursing
A minimum of two years of clinical experience is preferred, with home care experience strongly preferred
Experience working with vulnerable patient populations
Clinical experience working with patients with multiple complex health issues
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.
KNOWLEDGE AND SKILLS:
Excellent interpersonal skills and ability to work collaboratively
Self-management skills, including ability to prioritize and set patient-centered goals
Excellent written and verbal communication
Able to maintain professional boundaries
Ability to work with diverse, safety-net population
Skilled at engaging difficult to engage patients-build rapport, trust
Creative problem solver
Ability to adapt to changes in healthcare delivery at local and systems level
Extensive knowledge of healthcare systems and community resources
Ability to leverage systems and resources for improved patient outcomes
Strong organizational and time management skills
Working Conditions and Physical Effort:
Regular and reliable attendance is an essential function of the position.