Nurse Home Visitor

Nurse Home Visitor - Mabel Morris Program & CCSI

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National Nurse-Led Care Consortium (NNCC)
10% - Community Clinical Systems Integration (CCSI)
The Public Health Nurse Home Visitor (NHV) is responsible for providing comprehensive community nursing services to pregnant people and/or their families who are eligible for the Mabel Morris (MM) Family Home Visit Program in Philadelphia. The NHV maintains the highest standards in clinical practice and adheres to the Parents as Teachers (PAT) model. PAT's mission is to promote the optimal early development, learning, and health of children by supporting and engaging their families and caregivers. The NHV is a bachelor's level registered nurse who delivers curriculum to enrolled families who are raising children under five years old. The nurse and family work together to implement evidence-based strategies connecting resources needed to meet goals for their children and family's holistic health and educational well-being. NHVs partner with Philadelphia families to meet their goals by implementing and maintaining fidelity to the PAT model.
The NHV reports directly to the Mabel Morris Program's Public Health Nurse Supervisor and works in collaboration with other NHVs, administrators, and senior staff to build and improve the organization's strengths-based, client-centered culture. In-house topic experts and support staff support the NHVs.
All MM services are voluntary, non-clinical in nature, individualized, and focused on the expressed desires of the family. Services are family-centered, strengths-based, trauma-informed, and meet the needs of families in a respectful and culturally appropriate manner. The Mabel Morris Family Home Visit Program is a program of the National Nurse-Led Care Consortium (NNCC), a nonprofit organization working to strengthen community health through high-quality, compassionate, and collaborative nurse-led care. MM NHVs split their time between NNCC's West Philadelphia office (4601 Market Street) and fieldwork in the homes and communities of families served.
In this position, the NHV is also accountable to the Community Clinical Systems Integration (CCSI) initiative for 10% of their time.
Complete all required PAT and NNCC education, including but not limited to Life Skills Progression, Bracken School Readiness, and Ages and Stages Developmental and Social Emotional Assessments.
* Provide regularly scheduled in-home visits and telehealth visits for clients.
* Build and maintain a caseload of 18-20 active families raising children under five years old within nine months of employment.
* Plan home visits in accordance with client goals and PAT outcomes. Document all work appropriately.
* Support the achievement of client-identified goals through one-on-one education, active listening, screening, and referral processes to community resources.
* Support the policies, procedures, guidelines, and standards of PAT and NNCC.
* Adhere to ANA and PA nursing process and standards, code of ethics, HIPAA confidentiality standards, and the PAT model of home visitation.
* Contribute to and participate in clinical case conferences and professional development meetings including weekly team meetings, organizational all staff meetings, and regional, state, and national PAT education sessions.
* Meet twice monthly with the PAT supervisor for clinical reflective supervision and utilize the reflective process in supervisory sessions.
* Utilize the nursing process to assess, plan, and document the physical, emotional, social, and environmental needs of clients and their families as they relate to the PAT domains.
* Schedule joint home visits with the PAT Supervisor every six months (2 times a year).
* Collaborate with outreach staff regarding community referral sources and disposition of referrals to the MM program.
* Contribute to a positive work environment that enables all staff to function at their highest potential.
* Review documentation and data system reports entered in state, local, and national databases for accuracy, uniformity, and completeness.
* Engage in ongoing professional development and training in relevant areas including but not limited to motivational interviewing, mental health wellness, intimate partner violence, cultural consciousness training, as well as regional and state education sessions.
* Identify the impact of systemic injustice on the perpetuation of health inequity and demonstrate a commitment to advocacy efforts that support all Philadelphia families. Attend meetings with the Community Clinical System Integration (CCSI) workgroup to discuss efficiencies and reduce the burden on both NHV and pediatric providers, enhance coordination of care for families, and continue to identify areas of alignment in care delivery.
* Implement strategies identified by the CCSI team with quality and participate in quality improvement efforts that aim to improve strategies for integrated care.
* REQUIRED SKILLS & QUALITIES:
* Professional speaking and writing skills that are flexible and responsive to the audience being served at any given time
* Moderate to advanced computer skills
* Comfortable engaging with children and families in play, song, and story
* Able to work collaboratively with professionals, families, and community members
HIGHLY DESIRED SKILLS & QUALITIES:
* Demonstrated commitment to valuing diversity and contributing to an inclusive working and learning environment
* Educates, participates, and perpetuates the pillars of social justice
* Interest in special projects as needed
* Bilingual (Spanish preferred)
Current Pennsylvania nursing licensure in good standing
* Work or student experience in public health, prenatal-child health, mental health/behavioral health, or a related field such as early childhood services in community settings
* Bachelor's degree in nursing from an accredited university
* Flexible schedule including 2-3 early evenings every week required and option to work Saturdays
* Physically able to perform the job in home and community environments
* Light to moderate lifting and transport of program/client materials
* Work assignments involve travel throughout the designated area to multiple locations, including government and private agencies and partners.
* Prolonged computer-related exposure, as well as sitting and standing at workstations for long periods of time
* Local to regional travel as required by agency and funders
If selected for the 2023-2025 Fiscal Years Community Clinical Systems Integration (CCSI) initiative, the overview and responsibilities, in addition to the PAT model responsibilities, are outlined below:
The CCSI project is a strategic partnership between the National Nurse-Led Care Consortium and the Public Health Management Corporation with the Children's Hospital of Philadelphia (CHOP) PolicyLab and the CHOP Primary Care Network to design and implement an integrated system of care between evidence-based home visiting services and pediatric primary care with enhanced support for family engagement in quality childcare. Through a shared staffing model, the Nurse Home Visitors will work with CHOP pediatric primary care providers to promote greater positive healthcare outcomes with clients/patients/families over time that address social determinants of health. Nurse Home Visitors bring unique and valuable public health expertise that this partnership will use to augment primary care services in defined locations. Alignment and coordination of preventive services delivered in the home and office settings will increase the efficiency and quality of care for children served by nurse home visitors and pediatric primary care providers.
Public Health Nurse and Integration Specialist:
This is a full-time position funded .90 FTE nurse home visitor serving clients as determined by the evidence-based model and .10 within integrative care efforts. 10 FTE will be used to support the continued implementation of the identified integration strategies with additional responsibilities to be determined in collaboration with NFP nursing supervisor(s), CHOP designated nurse manager(s), and the project planning team to support the role of ambulatory care and the goals of NFP to meet pilot project determined deliverables. The following deliverables/responsibilities for this integration project are detailed below and are complimentary of the PHN Nurse Home Visitor responsibilities detailed above.
* Serve as a core member of the integration planning team which has the responsibility to design, implement, and evaluate the success of the piloted integration model.
* Serve as a member of the clinical care team for the CHOP Care Network pilot site, including care team communication, referral coordination, and other clinical responsibilities to be determined by the integration planning team.
* Exhibit proficiency in basic data requirements by program and state database. Receive training to be proficient in EPIC data entry.
* Contribute to the ongoing planning processes that frame a written document outlining alignment with evidence-based home visitation model and pediatric primary care providers and enrolled clients/families.
* With others, determine quality improvement initiatives that will be evaluated over time.
* Adhere to all CHOP educational requirements including annual safety protocols and updates to the patient electronic medical record system (EPIC).
* Document alignment and services including parent/child health and development screenings as determined by the integration team - such as Ages and Stages, using EPIC.
* Collaborate with PolicyLab staff, primary care providers, nursing clinicians, and NFP/Mabel Morris colleagues, supervisors, and others as designated to develop positive, productive, and reciprocal communication strategies that support family health. Share lessons learned and program outcomes with colleagues, interested organizations, and providers at local/national conferences.
* Communicate with the PolicyLab CCSI project director when necessary.
* Function as a CHOP/NFP/MM liaison with individual teams as well as all staff as needed.
Current Commonwealth of Pennsylvania Child Abuse Clearance or pending
* Current Nursing Malpractice Insurance coverage
* Current flu and COVID-19 vaccination documentation