|Title:||Nurse Care Coordinator|
|Department:||Adult Outpatient Services|
|Location:||1220 Willis Avenue, Daytona Beach, FL 32114|
Working Hours: 40 hrs week; Mon-Fri; 8a-5p
A currently competent nurse who provides clinical assistance to the Primary and Behavioral Health Care Integration (PBHCI) Health Home grant. The Nurse Care Coordinator assists patients referred to Primary Care and Wellness Services in accessing and utilizing coordinated healthcare resources and managing complex chronic illness. Their role is to improve health outcomes through coordinating integrated care, educating patients, building trust between patients and providers and enhancing communication and continuity of care. They will teach, counsel and monitor patients on physical and behavioral health issues relevant to their care and wellness. As a member of a multidisciplinary team they will consult with other health care team members to coordinate patient centered services. The Nurse Care Coordinator works to improve care quality and health outcomes while ensuring the efficient and effective use of healthcare resources. The Nurse Care Coordinator demonstrates technical skills in the Essential Job Functions, a thorough knowledge of the principles of integrated care and a working knowledge of grant and integrated healthcare services.
State of Florida Registered Nurse, 2 years experience in psychiatric setting or two years experience in a primary care setting.
- Knowledge of patient teaching, health promotion and disease self-management related to routine health care and of interventions designed to address the needs of patients with chronic, disabling health conditions and severe and persistent mental illness.
- Considerable knowledge of primary care, mental illness and substance use disorders and of all treatment, procedures, medications and side effects relating to integrated care clients.
- Ability to develop a collaborative therapeutic alliance with individuals served and other members of the integrated healthcare team.
- Providing assistance to patients in accessing and utilizing health care resources needed due to complex chronic illness.
- Coordinating care, educating patients, building trust between patients and providers, and enhancing communication and continuity of care.
- Assist with defining scope of care, building collaborative relationships and infrastructure and maintaining fidelity to program values and goals.
- Assist with establishing and maintaining relationships with community partners.
- Consult with other health care team members to coordinate the services of patient education, preventive care and disease management.
- Complete a basic initial face to face screening with new referrals to the primary care program.
- Review intake paperwork evaluating the individual for criteria, scope of care and referral, approving an individual for admission to the program in consultation with ARNP.
- Obtaining and reviewing prior medical records and medical history evaluating for scope of care in consultation with ARNP.
- Performing intake assessment with new patients, assessing patient integrated healthcare needs and cognitive/verbal skills and identifying any barriers to accessing care.
- Under standing orders, accomplish laboratory testing and referral for preventive health needs, including immunization, family planning, STI and cancer screenings, as indicated.
- Provide patient education and facilitate screening and prevention for HIV, other STIs and Hepatitis C and document in Avatar according to protocol.
- During initial and follow up visits identify patient symptoms, signs and health behaviors/needs and document education and interventions in Avatar.
- During initial and follow up visits identify patient educational needs and provide guidance and tools to aid patient and family/caregivers in managing chronic disease(s) effectively.
- At required intervals and as indicated obtain and document patient vital signs and key health indicators (per NOMs) and document in Avatar.
- Monitor patients for changes in health status after medication change, change in key health indicator(s), hospitalization or any assessed decline in function or presentation.
- Monitor lifestyle factors affecting health - such as tobacco use, substance abuse, nutrition and physical activity - and assist the patient with goal-setting to achieve behavioral change.
- Encourage the patient to engage in wellness programs offered by SMA and in the community.
- Coordinate and facilitate patient access to community resources, indigent, patient assistance and pharmaceutical assistance programs as well as other SMA programs or providers.
- Participate in regular (weekly at minimum) staffing meetings focused on coordinating patient care within the primary care team.
- Serve as a consultant to the rest of the health care team for educational resources, reviewing them for language, cultural competency and reading level and maintaining a library of updated patient education materials.
- Ensure that each patient receives medication education and anticipatory guidance relating to current regimen, newly prescribed medications and any OTC or supplements used.
- Conduct assessments, patient education and urine drug screens for Vivitrol clients in office on scheduled days.
- Administer injections of Vivitrol, ensuring adherence to protocol and ongoing client informed consent.
- Document all services relating to Vivitrol in Avatar.
- Communicate with staff in all departments/programs regarding patient contacts, progress, referrals, changes in patient condition or services used.
- Holding all client information in confidence and maintaining PHI in accordance with all applicable laws and agency policy.
- Ensuring adherence to Evidence Based Practice in all areas of care and documenting the delivery of Evidence Based care.
- Participates in PBHCI grant program webinars, conference calls, and meetings and disseminate information to clients, other providers and partners.
- Participates as member of a treatment team with physicians, ARNP, integrated care managers, therapists, etc. Participates in staffing and formal treatment planning with therapists, integrated care managers and providers from community treatment programs.
- Organizational and time management skills
- Verbal and written communication skills
- Decision making and problem solving skills
- Makes commitment to SMA's misson and core values the SMA Way
- Abides by principles of EEO compliance and a workplace of dignity and respect
- Works cooperatively in a group/team setting
- Shows respect to others
- Takes guidance and direction from supervisors
- Arrives/Reports to work on time and ready to work.
EEO Employer W / M / Vet / Disabled