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.

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.

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.

Preferred Qualification:

• Bilingual in English and Spanish Preferred
• EPIC experience preferred

CORE JOB RESPONSIBILITIES

As a Clinical Care Provider, you will adhere to state regulatory guidelines for Registered Nurses, performing comprehensive triage and providing advice for both phone and walk-in patients. You will use sound judgment and clinical skills to provide immediate responses for urgent triage, including phone and in-facility emergencies. Under provider direction, you will conduct nurse visits, managing tasks such as medication refills, chronic care management, lab results review, medication reconciliation, wound care, and dressing changes. Identifying significant clinical findings, making conclusions, and intervening appropriately are crucial aspects of this role. You will also accurately and promptly implement provider orders using your nursing judgment, demonstrating knowledge of therapeutic actions, side effects, and interactions of medications.

In your role as a Care Manager, you will collaborate with providers and care team staff to identify and monitor patients for care management. Ensuring patients follow provider directives and identifying any obstacles they may face will be essential. You will follow care management protocols for patients with chronic diseases or multiple medical problems, including ordering tests, referrals, and immunizations. Acting as a comprehensive care coordinator, you will assess patient needs and facilitate communication among providers. You will perform thorough assessments of patients’ physical, emotional, psychosocial, and environmental needs and develop, revise, and implement patient care plans based on status changes, ensuring receipt of all recommended preventive services. Identifying and arranging needed community resources and tracking and providing appropriate follow-up for patients seen in the emergency room or hospitalized will also be part of your duties.

As a Patient Educator, you will educate patients on medication use and the management of chronic conditions like asthma, diabetes, and obesity. You will develop, organize, and execute health educational programs based on healthcare guidelines to promote health maintenance and disease prevention.

Administratively, you will write and update policies and procedures to maintain compliance with Patient-Centered Medical Home guidelines. You will initiate, coordinate, and enforce program, operational, and personnel policies and procedures to ensure smooth nursing operations. Additionally, you will schedule and assign nursing staff to meet patient care requirements and follow up on work results.