Under the general supervision of the PCMH Manager, the Community Health Nurse provides comprehensive home visit nursing services through a referral-based process. The incumbent collaborates with the Care Coordination and Case Management multidisciplinary team to address the clinical and psychosocial needs of referred patients and families. The Community Health Nurse focuses primarily on direct patient care, chronic disease support, patient education, and coordination of services in home and community settings. The position operates within established nursing standards, policies, and physician standing orders and supports program goals without primary responsibility for program development, strategic planning, or data analysis. Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.
This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.
Essential Duties & Responsibilities:
-
Maintains regular attendance and punctuality.
-
Provides direct home visit nursing care to referred individuals and families across the lifespan.
-
Performs comprehensive nursing assessments and develops individualized care plans within scope of practice.
-
Implements physician standing orders and established clinical protocols.
-
Implements a patient centered-home visit nursing care services within the standards of care and the nursing scope of practice.
-
Identifies high-risk patients and reports findings to the PCMH Manager and Care Coordination team.
-
Coordinates and participates in the planning, implementing, and addressing psychosocial issues and concerns in patient care.
-
Provides education, coordinates, and case manages referred patients living with chronic disease illnesses via home visit program.
-
Provides home care self-management education to clients.
-
Follows the Standards of Care guidance for the various chronic disease illnesses and home visit policies and procedures.
- Provides/Facilitates/Coordinates Self-Management Education classes in the communities.
-
Identifies and prioritizes care to clients with high-risk conditions.
-
Documents patient encounters via Electronic Health Record using the community health nursing template that incorporates patient self-assessment and goal setting information.
- Provides primary, secondary, and tertiary prevention activities in the community i.e. health fairs.
- Assists the PCMH Manager, Care Coordination, and Case Management teams to develop, implement/monitor, and evaluate/revise program policies and procedures, protocols, and standing orders.
-
Participates in quality assurance activities to improve access to care and services for patients living with chronic disease illnesses and clinical outcomes.
- Maintains proficiency and knowledge in trends affecting nursing issues such as treatments, concepts, skills, and nursing theories through continuing education, workshops, staff meetings, and Improving Organizational Performance team committees.
- Supports emergency response activities and follows established emergency preparedness protocols.
-
Maintains compliance with professional nursing standards and scope of practice.
-
Maintains required certifications and continuing education.
-
Requires completion of tasks or duties assigned by a supervisor.
- Upholds all principles of confidentiality and patient care to the fullest extent.
- Adheres to all professional and ethical behavior standards of the healthcare industry.
-
Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
-
Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
- Possesses cultural awareness and sensitivity.
- Maintains compliance with all Human Resources requirements.
- Performs other duties as assigned.
Minimum Qualifications:
Associates degree in Nursing and minimum of one year experience in clinical nursing required; community or public health experience preferred. Must be licensed as Registered Nurse in the state of Arizona (excludes USPHS commissioned officers). Current CPR, BLS, ACLS, PALS, and NRP certification required or obtained within six (6) months of hire. A certification in Public/ Community Health Nursing preferred. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).
Knowledge, Skills, Ability
-
Knowledge of principles of community/public health nursing.
- Knowledge of chronic disease management and patient education techniques.
- Knowledge and ability to incorporate the Patient Centered Medical Home aims into the community health home program.
- Knowledge of adult learning and health education techniques and principles including: reproductive health education, related services information, option counseling and emergency contraception services.
-
Knowledge of anatomy, physiology, pathophysiology, epidemiology, physical assessment and basic pharmacology.
-
Knowledge of human systems (wellness, illness, growth and development, basic nutrition, human behavior, psychosocial development, family and community systems).
-
Knowledge of prescribed treatments and medical interventions; ability to effectively monitor and document the patient’s treatment progress and response; ability to refer to appropriate providers as indicated.
-
Knowledge of health care technology, equipment, supplies and materials needed for medical treatment.
-
Knowledge of Electronic Health Record documentation, medical record forms, State and Federal Laws that govern release of information, and patient consent.
-
Knowledge of and awareness of cultural and language differences.
- Knowledge of communicable disease outbreak, medical emergencies, and other unforeseen causes.
-
Knowledge of emergency preparedness, at home, work and in the community.
-
Knowledge of incident command structure and its use in the community; public health nurse is a first responder.
-
Knowledge of relevant OSHA Standards.
-
Knowledge of the National Incident Management System (NIMS)/Incident Command System (ICS) 100, 200 and 700.
- Knowledge of strong work ethics in the workplace.
-
Knowledge of basic application of confidentiality.
-
Knowledge of duties and responsibilities of the position.
-
Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
-
Ability to be dependable in attendance and job performance.
-
Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
-
Ability to travel and make home visits including in inclement weather.
-
Ability to demonstrate professional conduct and upholds the nursing practice standards of care set forth by the State Board of Nursing.
- Ability to be dependable in attendance and job performance.
-
Ability to work in unstable family settings and high risk neighborhoods.
-
Ability to accept and learn from feedback.
-
Ability to effectively communicate both in written and verbal.
-
Ability to provide exemplary customer service at all times.
-
Ability to interact positively with others and possess great interpersonal skills.
-
Ability to multitask and perform well under pressure.
-
Ability to have self-confidence.
-
Ability to be a great team player.
-
Ability to work collaboratively within a multidisciplinary team.
-
Ability to accept and learn from supervisor/peer critique.
-
Ability to be flexible and adaptable to the changing needs of the organization.
Physical Demands:
While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.
Work Environment:
Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.
As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.
