Description

CORE VALUES

The core values of Community Health Center of Southeast Kansas, Inc. (CHC/SEK) are dignity and stewardship. Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of the Center's resources.

GENERAL DESCRIPTION OF POSITION

The Health Promotion Department works to improve health outcomes, reduce the overall cost of care, and improve the patient experience within identified patient populations. These populations are identified through advanced healthcare analytics, quality metrics, and provider and care team referrals.

The Health Promotion Nurses are motivated and passionate about improving health outcomes of patients. They strive to understand, motivate, and help our patients achieve their goals in health and wellness by building rapport, eliminating barriers, collaborating with patients to set goals, and working within a multidisciplinary care team. This position is responsible for outreaching to patients who were recently discharged from an inpatient stay or emergency department visit.

To do this, the Health Promotion Nurse must be flexible, knowledgeable about disease processes, community resources and CHC/SEK care systems, and be able to address barriers to improve health outcomes.

Requirements

ESSENTIAL DUTIES

Engage assigned patients and work to decrease the impact of exacerbations on health and accelerate recovery through targeted care management. Provide coordination of care within an interdisciplinary team that further supports retention, wellness, and overall health.
Implement ongoing care management services to promote continuity of care, which may mean working with the same patient for an extended period of time.
Create and periodically update patient specific care plans that include clear goals, priorities, and realistic actions to achieve their goals. In addition to goal setting, care plans include performing medication reconciliations, obtaining complete medical history, health risk assessments, and preventive and behavioral health screenings.
Support care plan progress by scheduling annual exams and follow-up appointments, scheduling transportation, arranging prescription coordination, and/or other preventive care services, as needed.
Use skills like motivational interviewing and shared-decision making to engage patients in the development of health and social support goals, coaching patients in the effective management of their health conditions and utilizing self-care techniques.
Monitor for and review discharge notifications and information provided in EHR reports and payer portals. Collaborate with outside facilities to obtain timely discharge records and needed information.
Contact patients that have been recently discharged from an inpatient and emergency department settings to evaluate their status, complete a medication reconciliation, arrange any needed follow-up care, and to ensure a smooth transition back to primary care.
Assess for potential social determinants of health, evaluate patients for chronic care management services, connect with community and organizational resources, and discuss with patient’s provider, as appropriate.
Communicate necessary information to patient, provider, care team and other staff through clear and concise documentation.
Provide chronic disease education so patients understand more about their chronic conditions, related medications, and treatment plans.
Utilize resources (e.g. accountable care organization (ACO) data/informatics), technology, and telehealth platforms to better connect patients to care and provide nursing assessments, as needed.
Contribute to and utilize data to achieve program goals and improve patient health outcomes.
Help maintain a library of health promotion and patient education materials and community resources.
Assist in educating providers and support staff in value-based care initiatives, particularly around hospital visits/discharges and chronic care management.
Participate in quality improvement activities around emergency department utilization and hospital readmissions.
Actively participate in ongoing in-service programs, staff meetings, continuous quality improvement, and periodic performance/protocol evaluations and development.
Execute all duties and services in full compliance with CHC/SEK policies and procedures.

The essential functions listed are not an exhaustive list of every task the employee is required to complete. Employees are expected to perform all other duties as assigned.

QUALIFICATIONS

Possession of a valid multistate Registered Nurse or Licensed Practical Nurse license.
Two (2) or more years of RN/LPN clinical experience required.
Previous care management and/or behavioral health experience preferred.
Basic Life Support through American Heart Association, must be obtained within 90 days of hire.

KNOWLEDGE, SKILLS, AND ABILITIES

Thrive in working with technology and become proficient with the organization’s electronic medical record system.
Strong ability to communicate effectively both verbally and in writing.
Excellent documentation skills; notes must be logical, clear, and concise.
Must be organized and have strong attention to detail.
Familiarity/experience with communicating with patients, especially on the telephone.
Demonstrate problem-solving, prioritization, and time management skills.
Ability to multi-task and maintain integrity of work despite interruptions.
Demonstrate strong collaboration, team-work, and customer relation skills.
Must be capable of making independent nursing decisions and demonstrate knowledge of the rationale of appropriate patient care.
Ability to handle emergency situations calmly and effectively.
Must be able to maintain good interpersonal relationships with co-workers, other members of the health care team, and the organization.
Demonstrate social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base.
Communicate through appropriate channels and use the proper chain of command for patient complaints.
Provide customer service in accordance with the organization’s mission.
Be courteous and respectful when interacting with patients and family members.
Maintain confidentiality in accordance with the organization’s policy and procedure and HIPAA requirements.

WORKING CONDITIONS

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. While performing the duties of this job, the employee is regularly required to sit in front of a computer screen for prolonged periods of time, use a telephone/headset, keyboard, and mouse. Travel may be required throughout the service area.