Registered Nurse, Community Outreach Case Manager

The Community Outreach RN will provide direct clinical care and patient case management both within LSCHC clinics and in the community. This role will provide preventive health and acute care services in a mobile setting, serving people experiencing barriers to healthcare including homelessness and substance use. This role will also emphasize linkages between outreach and clinic settings, and the delivery of trauma-informed care across both spaces.

PRIMARY RESPONSIBILITIES

Professional Clinical Care and Clinic/Outreach-Based Care Coordination

1. Provide professional clinical care (including triage, assessment, intervention, evaluation) in fixed-site clinic as well as varying community settings, prioritizing trauma-informed care principles and patient-led care plans.

2. Deliver skilled interventions including, but not limited to, wound care and assessment, foot care, medication and vaccine administration, phlebotomy, education, standing orders, minor procedures if appropriate, and vital signs.

3. Conduct nurse-led or provider level visits through the utilization of standing orders.

4. Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.

5. Utilize harm reduction strategies to address health concerns disproportionately affecting unhoused populations including HIV, hepatitis C, STIs, wounds, foot health, asthma, diabetes, substance use disorder, overdose risk, and behavioral health concerns. Provide harm reduction services including naloxone, syringe and safer use supplies and education.

6. Perform assessments of patient’s unmet medical, behavioral, and social care needs and support the care team in meeting these needs. Help patients navigate community resources and specialty care, as well as linkages to primary care when needed. Work to reduce barriers through follow-up, transportation support, appointment reminders, and other strategies.

7. Provide advocacy on behalf of patients seeking outside care.

8. Work collaboratively with clinic staff to identify high-risk or out-of-care individuals. Offer mobile care coordination services and linkages to care as appropriate.

9. Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol.

10. Read and interpret patient charts and lab results. Review new labs and identify need for follow up. Communicate with other clinical providers as needed.

11. Assist patients in care transitions, such as entering or discharging from treatment, hospitalizations, respite programs, and shelters. Work with external service providers to ensure continuity of care.

12. Facilitate rapid access to HIV and hepatitis C care, PrEP, PEP, and buprenorphine for substance use disorder.

13. Support care plan and medication adherence through medication set up, delivery, and routine lab draws.

14. Performs clinical exams in clinic and outreach environments.

Outreach Program Implementation

1. In collaboration with other community agencies, implement policies and procedures to support mobile health services utilizing evidence-based practices and patient-centered care models.

2. Develop relationships with community organizations and individuals to ensure collaboration and partnership to advance program goals.

3. Communicate frequently and directly with team members on patient needs and direction of daily work and larger issues affecting the health status of homeless individuals.

4. Utilize staff teams within LSCHC to refer clients appropriately, including but not limited to the health advocates, primary care, behavioral health, chiropractic care, or others.

5. Initiate and lead targeted ‘in-reach’ and outreach to engage, educate, refer, and connect out-of-care patients to integrated health care services.

6. Document data, plans, clinical actions, client progress, response to care and other relevant patient information in EHR.

MISCELLANEOUS RESPONSIBILITIES

1. Assist in implementing and carrying out continuous quality improvement programs and activities.

2. Assist other team members.

3. Actively participate in staff meetings and inservices.

4. Participate in continuing education and professional growth.

5. Adhere to the standards and policies of the organization.

PHYSICAL DEMANDS

· Able to move about easily.

· Able to speak and hear clearly.

· Fast-paced environment.

· Exposure to communicable diseases.

OB QUALIFICATIONS AND CREDENTIALS

· Associate or bachelor’s degree in nursing from an accredited School of Nursing.

· Active and unrestricted Registered Nurse license in Minnesota and Wisconsin

· Able to provide health care in a sensitive, nonjudgmental manner to persons of all economic levels and cultural backgrounds.

· Capable of independent nursing assessment decisions and nursing management

· Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.

· Demonstrated ability to plan and manage projects

· Computer experience

· Willing to work flexible hours, including evenings, as required by position.

· Current CPR certification or ability to become certified within six months from date of hire.

· Public health nurse registration preferred

· Clinical experience in community health and outreach-based nursing preferred.

· Experience working with chemically dependent adults and knowledge of harm reduction principles preferred.

JOB KNOWLEDGE, SKILLS, AND ABILITIES

· Ability to work efficiently and productively at all times.

· Ability to maintain an even temperament with patients, staff and community partners

· Ability to prioritize and handle multiple tasks.

· Ability to work as a team member.

· Ability to use problem-solving and decision-making skills.

· Ability to use tact, collaboration, and diplomacy when working with others.

· Ability to understand and follow written and verbal instructions.

• Annual salary: 33280-40268 USD annual
• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (403b)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off (Vacation, Sick & Public Holidays)
• Family Leave (Maternity, Paternity)
• Short Term & Long Term Disability
• Training & Development