PRINCIPAL DUTIES AND RESPONSIBILITIES
· Host daily ‘Talk to the Nurse’ office hours.
· Assess client’s overall health utilizing a health indicator survey, establish health goals and timelines, and monitor clients for goals achievement.
· Provide health education on preventative care, chronic care management, and other pertinent topics of interest to senior clients.
· Facilitate regular support groups for clients with specific issues (diabetes, pain, depression, vision loss, etc.).
· Screen and monitor clients for chronic disease including regular checks of clients’ blood pressure, weight, medication adherence, and blood glucose.
· Identify clients with multiple chronic conditions at increased risk for functional decline or death and coordinate health care services as appropriate.
· Identify clients for needed mental or behavioral health services through a team-based collaborative approach to care.
· In collaboration with Senior Services Case Managers, develop client health intervention plans with regular follow-up on progress toward health goals.
· Identify patients discharged from hospitals, outpatient observation clinics, skilled nursing facilities, and community mental health centers for follow-up care.
· Provide client referrals and registrations to Betances for primary care and care management.
· Provide oversight to ensure and maintain patient flow to providers and efficient discharge back to Senior’s residence.
· In collaboration with Senior Services Case Managers, visit homebound seniors to identify clients in need of clinical home care and make referrals as needed.
· Participation in Henry Street Settlement and Betances staff meetings
Knowledge, Skills and Abilities Required
· Excellent communication, interpersonal, organization, and leadership skills.
· Assertive, detail-oriented, and able to handle multiple tasks simultaneously.
· Intermediate computer proficiency in Microsoft Word and Excel.
· Bilingual (Spanish/English or Chinese/English) preferred.
Education and Experience Required
· NYS Licensed Registered Nurse with 5-7 years experience in a Primary Care Center or Ambulatory Center. Will consider comparable inpatient experience. BCLS certification required.
· BS/MS Nursing
Job Type: Full-time