RN Outreach Case Manager

3 months ago

Minneapolis, United States Native American Community Full time
Job DescriptionJob Description

SUMMARY: The Community Outreach RN will provide direct clinical care and patient case management in the community alongside the Outreach and Harm Reduction Teams. NACC’s clinical outreach program will provide preventive health and acute care services within a mobile unit and in other outreach settings, focusing on serving people experiencing barriers to healthcare including homelessness and substance use.

DUTIES AND RESPONSIBILITIES:
  • Professional Clinical Care and Outreach-Based Care Coordination
    1. Provide professional clinical care (including triage, assessment, intervention, evaluation) in varying community settings, prioritizing trauma-informed care principles and patient-led care plans.
  1. 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.
  2. Conduct nurse-led or provider level visits through the utilization of standing orders.
  3. Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.
  4. 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.
  5. 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. Provide advocacy on behalf of patients seeking outside care.
  6. 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.
  7. Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol.
  8. Read and interpret patient charts and lab results. Review new labs and identify need for follow up. Communicate with other clinical providers as needed.
  9. 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.
  10. Facilitate rapid access to HIV and hepatitis C care, PrEP, PEP, and buprenorphine for substance use disorder.
  11. Support care plan and medication adherence through medication set up, delivery, and routine lab draws.
  12. Performs clinical exams in clinic and outreach environments.

  • Outreach Program Implementation
    1. In collaboration with other Outreach, Medical, and Harm Reduction staff, implement policies and procedures to support mobile health services utilizing evidence-based practices and patient-centered care models.
    2. In partnership with Outreach Provider, implement health services for people who use drugs delivered out of a new community drop-in space.
    3. Develop relationships with community organizations and individuals to ensure collaboration and partnership to advance program goals.
    4. 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.
    5. Utilize staff teams within NACC to refer clients appropriately, including but not limited to the patient advocate, population health, MAT services, infectious disease treatment, and other teams.
    6. Initiate and lead targeted ‘in-reach’ and outreach to engage, educate, refer, and connect out-of-care patients to integrated health care services.
    7. Document data, plans, clinical actions, client progress, response to care and other relevant patient information in EHR.
SUPERVISORY RESPONSIBILITIES:
  • Does not directly supervise staff.

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