Care Plan Nurse

Summary

Care Plan Nurse - RN assumes advocacy and accountability to an identified group of patients as part of the Patient-Centered Medical Home (PCMH) during all or part of the continuum of care. Provides a single standard of care to patients using evidence-based disease state management clinical pathways. Focuses on primary disease prevention improving the quality of care for chronically ill patients and outreach to patients to be more engaged in their overall health and wellness.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Collaborates with the health care team responsible for patient care to develop, implement, monitor, and evaluate appropriate clinical care and other health care services to meet the needs of the patient and helps coordinate all activities, including accreditation within the PCMH.

Directs and assists the primary care team in recognizing and managing clinical health and psychosocial issues and acts as a contributing member of the primary care team as part of the Patient-Centered Medical Home (PCMH) during all or part of the continuum of care. Acts within the scope of his/her license provisions as applicable.

Works closely with and communicates effectively with the Medical Team to coordinate patient care and education; provides information for assessments under the supervision of the primary care provider; coordinates appointments for nutritional, health, and medical visits.

Ensures that areas of responsibility are operating in compliance, including documentation and records with all federal, state, programmatic, and regulatory agencies.

Identifies patients to be case managed, assesses patient's care requirements, modifies, or coordinates modification of patient care, and intervenes as necessary.

Coordinates in the development and review of clinical pathway trends and shares with appropriate service and management teams.

Assists with monitoring of quality improvement elements including establishment of program measures and implementation of action plans.

Monitors trends and implements strategies to assist patients with accessing appropriate levels of care.

Reviews and understands strategies to assist patients with accessing appropriate levels of care.

Documents the clients' progress information in the patient's EHR.

Provides clients with self-management skills and educational information needed so they can be full participants in their treatment and care.

Act as Liaison for Family Circle of Care.

Compliance with FCC Standards of Conduct, Code of Conduct, and the Quality and Compliance Program.

Participates in quality improvement and Patient-Centered Medical Home (PCMH) activities.

Maintains current knowledge of community resources and assists with patients' access. Maintains current knowledge base in best practices and reviews evidence-based literature involving disease state management.

Participate in quality improvement activities.

Supervise a team of LVN care coordinators.

Attending meetings, seminars, and conferences as appropriate to ensure skills and knowledge remain current.

Other duties as assigned.

Patient-Centered Responsibilities

Maintains awareness of the comfort and safety needs of patients.

Observe patients, record significant conditions and reactions, and notify the supervisor or Physician of the patient's condition and reaction to drugs, treatments, and significant incidents.

Takes temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and assess the condition of the patient.

Documents nursing history and physical assessment for assigned patients.

Supervisory Responsibilities

The lead role aids the Quality Improvement Director and provides technical expertise to clinical employees including LVN Care Coordinators, MAs, and CCMAs. Carries out supervisory responsibilities following the organization's policies and applicable laws. Responsibilities may include training employees; planning, assigning, and directing work; appraising performance; addressing complaints, and resolving problems.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Customer Service - Manages difficult or emotional customer situations; responds promptly to customer needs; responds to requests for service and assistance; meets commitments.

Communications - Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.

Team Leadership - Fosters team cooperation; ensures progress toward goals.

Leadership - Inspires and motivates others to perform well; effectively influences actions and opinions of others; gives appropriate recognition to others.

Diversity - Shows respect and sensitivity for cultural differences.

Ethics - Treats people with respect; inspires the trust of others; works with integrity and principles; upholds organizational values.

Personal Appearance - Dresses appropriately for position; keeps self well groomed.

Attendance/Punctuality - Is consistently at work and on time; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time.

Safety and Security - Observes safety and security procedures; reports potentially unsafe conditions; uses equipment and materials properly.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

Education and/or Experience

Bachelor of Science in Nursing. At least one year of nursing experience in a clinical setting or hospital is preferred.

Computer Skills

To perform this job successfully, an individual should know Microsoft Word Processing software, Microsoft Excel Spreadsheet software, and Electronic Medical Record experience. EPIC experience preferred.

Equipment

Point of Care Testing with glucose meters, blood pressure monitors, and other POCT equipment.

Certificates, Licenses, Registrations

A current GN permit or RN License in the state of Texas is required. Responsible for maintaining licenses and obtaining all professional CEUs in compliance with Licensure Boards and City, State, and Federal Regulations. The current BCLS Healthcare Card is renewed every two years.

CORE JOB RESPONSIBILITIES

(Essential Duties): Clinical Care Provider
• Adheres to the scope of practice for Registered Nurses per state regulatory guidelines.
• Performs comprehensive triage and advice (phone and walk-in), demonstrating appropriate judgment and skills to be able to make independent clinical decisions in routine patient care matters.
• Provides immediate response for urgent triage (includes phone) and codes within the facility Performs nurse visits under the direction of Provider(s), including but not limited to Medication refills, chronic care management, review of lab results, medication reconciliation, wound care, and dressing changes, both in-person and telephone appointments.
• Identifies significant clinical findings, makes conclusions, and intervenes appropriately.
• Implements providers' orders accurately and promptly, using nursing judgment.
• Demonstrates knowledge of therapeutic action, side effects, and interaction of medications. Care Manager
• Collaborates with providers and care team staff to identify and monitor appropriate patients for care management.
• Ensure patients are adhering to the provider's directives, identifying any obstacles patients may have.
• Efficiently and accurately follows care management protocols for patients with chronic disease(s) and/or multiple medical problems, including ordering appropriate tests, referrals, and immunizations.
• Acts as a comprehensive care coordinator for assigned patients, assessing patients' needs and facilitating communication amongst other providers.
• Performs comprehensive assessment of physical, emotional, psychosocial, and environmental needs of patients.
• Participates in the development of patients' goals and care plans as well as makes revisions to these based on changes in patient status. Ensures receipt of all recommended preventative services.
• Identify and arrange needed community resources.
• Tracks and provides appropriate follow-up for patients seen in the emergency room or hospitalized per protocols. Patient Educator
• Provides individual patient education on topics including but not limited to medication use; and management of asthma, diabetes, obesity, and other chronic conditions.
• Develops, organizes, and plans the execution of health educational programs based on our health care guidelines to promote health maintenance, prevention of chronic disease, and prevention of complications of chronic diseases. Administrative
• Maintains nursing guidelines by writing and updating policies and procedures in compliance with Patient-Centered Medical Home.
• Maintains nursing operations by initiating, coordinating, and enforcing program, operational, and personnel policies and procedures that comply with the Patient-Centered Medical Home.
• Completes patient care requirements by scheduling and assigning nursing and staff, following up on work results.