Full Job Description
Job Description Summary:
Community Health Center, Inc. (CHC), with offices in Connecticut, Colorado and California, is one of the country’s most creative and dynamic providers of primary medical, dental, and behavioral health services, and a leader in practice-based research, health professionals training, and use of innovative technologies to advance health and healthcare. CHC is designated as a federally qualified health center and a patient-centered medical home by HRSA, the Joint Commission, and NCQA, respectively. We deliver more than 500,000 patient visits per year from primary care hubs and community clinics across the state of CT, all connected by technology and common standards for quality. We employ several hundred medical, dental, and behavioral health providers who are engaged in practice, teaching, and research. Our Weitzman Institute is devoted to research and practice transformation and is recognized around the country as one of the premier research institutes focused on improving health care and health outcomes for special and vulnerable populations. In addition, the organization has developed three wholly owned subsidiaries from the original pilot developments within the Weitzman Institute: the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC), the National Institute for Medical Assistant Advancement (NIMAA), and ConferMED.
The Primary Care Nurse (PCN) provides high quality, comprehensive, professional primary nursing care to individuals and families throughout the lifespan. As part of a clinical team, the PCN works at the top of his or her licensure to enhance the safety, effectiveness, and efficiency of care through both the performance of professional nursing responsibilities and the delegation of technical and clerical functions as appropriate to medical assistants. Provides patients with both general and focused health education regarding preventive, chronic, and episodic health care issues. Assumes responsibility, in collaboration with primary care providers, other PCNs and other members of the care team to coordinate care, support transitions between levels of care, and counsel, educate, and support patients in improving health status. The PCN applies principles of advanced access, planned care and the chronic care model, and rapid cycle performance improvement using the PDSA approach at CHCI.
This is a grant-funded position focusing on innovative methods for delivering technology-enhanced Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use disorders. In this role as the Population Health Nurse, supporting the SBIRT grant, the PCN will support the mission of CHCI to improve health outcomes by focusing attention on groups of patients as well as individual patients identified as having or likely to have gaps in care, adverse health outcomes, or suffer from health inequities related to social, racial/ethnic, environmental, and economic determinants of health. This position is fully funded through March 2022 at which time this position will be re-evaluated.
ROLE AND RESPONSIBILITIES
Reviews data reports daily to identify patients eligible for a technology-enhanced Screening, Brief Intervention and Referral to Treatment (SBIRT) sessions
Reaches out to patients to offer enhanced SBIRT via telehealth
Works collaboratively with the patient to identify action steps and monitors patient progress on action steps through online tools and follow-up visits
Develops expertise on internal and external substance use disorder treatment resources and protocols
Connects patients with treatment resources, as needed
Attends weekly meetings with project team to track progress towards program enrollment goals
Works with project director to ensure fidelity to intervention methodology
Reviews other care gap reports as needed to coordinate care
Engages patients in care coordination and management as needed, directly or through coordination with assigned primary care RN or behavioral health provider
Coordinates resolution of care gaps directly with patients or indirectly with primary care team members
Through the course of telehealth visits, supports the primary care of patients under planned care model, including pre-visit planning, daily and e-huddles, and execution of nurse-led and nurse-assisted visits.
Collaborates with PCP to identify needs for preventive care, evidence based chronic disease care, and care coordination where applicable.
Provides general and specific health care education during patient visits and by telephone.
Works with patients to identify and monitor self-management goals.
Collaborates and coordinates care with other community-based providers. Follows up on emergency room visits and hospital discharges where applicable.
Ensures safe, accurate, clinically appropriate collection, storage, and processing of all biologic specimens, when applicable.
Administers medications, including immunizations, at the order of prescribing provider and understanding orders as established by CHCI, when applicable.
Adheres to CHC protocols regarding documentation of medication, route, dosage, and information provided to patient.
Monitors patient response to medication based on specific medication administered; detects, reports, and responds to any adverse reaction. Reconciles medications. Provides patient education as appropriate to the administered medication.
Participates and manages protocol-based triage as needed telephonically, or through direct assessment if in-person
Accurately documents all aspects of patient care in the medical chart on a timely basis.
Maintains strict infection control standards in accord with CHCI protocols and universal precautions TJC, OSHA and CLIA standards.
Acts as a resource person for medical assistants regarding patient preparation, needs and procedures needed.
Monitors and ensures follow up of all abnormal cancer screening results such as pap smear and colorectal cancer screening results, STDs, lead screens and other tests and screens performed at CHCI where applicable as a part of planned care for telehealth visits.
Maintains compliance with agency mandatory annual training (Patient Safety, Abuse, Age Based Competencies, EOC, Abuse trainings, etc.)
Expert use of electronic health record to ensure timely, safe, confidential storage and retrieval of patient information.
Actively enrolls and manages complex, chronically ill patients in their complex care management panel, ensuring accurate documentation within the E.H.R.
Participates in ongoing population health initiatives.
Participates in Project ECHO complex care management to continually advance knowledge and skills in care management and care coordination.
Presents nursing information and insight into patient care with other members of the care team at Integrated Care Team meetings.
Participates in training the next generation.
Exhibits excellent customer service skills to external and internal customers at all times with a focus on quality of care and teamwork that focuses on the needs of the department and/or the business in conjunction with the full mission of the Agency
Required Skills and Education
Registered nurse, in good standing.
Experience with skills such as medication administration, including immunizations, word processing and computer skills, familiarity with medical testing procedures, and motivational interviewing and self-management goal setting
Applicant will also possess sound organizational skills and accuracy at all levels of job.
Prior demonstrated excellent communication and customer service skills.
Must be team focused and demonstrate leadership qualities.
Bilingual in English and Spanish
Expert knowledge of the electronic health record
1+ year of experience as a nurse in ambulatory care, preferred. New graduates and experienced nurses from other settings with a strong interest in chronic disease management and primary care nursing are encouraged to apply.
Experience delivering Screening, Brief Intervention and Referral to Treatment (SBIRT) or specialty SUD treatment
Proficiency in use of Excel
Current CT Nursing License
CHC requires as a condition of employment current American Red Cross CPR for the Professional Rescuer and AED (CPR/FPR/AED) certification. The only acceptable alternative is current American Heart Association BLS/AED for Healthcare Providers certification.
PHYSICAL REQUIREMENTS/WORK ENVIRONMENT
Requires manual dexterity to perform clinical tasks, moderate physical activity including standing, walking and lifting.
Potential exposure to blood borne pathogens and/or bio-hazardous material.
Frequent and alternating standing, walking and sitting
Occasional bending, squatting, kneeling and lifting up to 25 pounds.
Daily and continuous computer use.
Daily and frequent telephone use.
Excellent oral and written communication skills are required.
This position must interface with patients, family members, community agencies and other providers within the organization.
CONFIDENTIALITY OF INFORMATION:
Personal Health information is kept in strict confidence. Confidentiality of patient and business information is a requirement. Full access to patient medical records and encounter data. Confidentiality must be maintained according to CHC policies.
Responsibility for client data entry
Access to medical system information.
Confidential patient correspondence.
Community Health Center of Middletown