Hhome / Clinic Rn Case Manager

3 weeks ago

San Francisco, United States San Francisco Community Health Center Full time

The HHOME/Street Medicine RN Case Manager will help plan, coordinate, and oversee nursing services for both the HHOME team (40%) and the SFCHC Street Medicine team (60%).

The Homeless HIV Outreach and Mobile Engagement (HHOME) program provides intensive care management for patients living with HIV and simultaneously experiencing homelessness. The RN will oversee adherence and nursing care for the HHOME program by collaborating with case managers and primary care providers in designing treatment goals and intensive care coordination. In addition to clinical support, the RN will help us achieve program administrative goals, such as documenting and tracking patient outcomes.

The RN will also be a clinical member of SFCHC’s Street Medicine team. In this portion of their role, the RN will work in collaboration with providers and other members of the Street Medicine team to manage patient care, complete medication refills, design and implement complex care plans that address patient-centered goals.

In both roles, medical care will happen in both clinical and community settings, including drop-in clinics, on sidewalks, in tents and encampments, or in patient homes. The RN must be comfortable working in non-traditional care settings and providing care to people who use substances, with complex mental health and medical diagnoses. In addition, the RN will work collaboratively with community partners and area hospitals to coordinate care across the continuum and accept referrals for patients who would benefit from connection to mobile primary care. Opportunities will be available for professional growth and development through participation in educational programs, review of current literature, in-service meetings, and workshops.

**Essential Functions**:

- Serves as an integral member of the clinical and interdisciplinary HHOME and Street Medicine teams to provide wrap-around services/care for clients in a team-based care model.
- Performs nursing assessments for primary care patients in both non-traditional and traditional settings.
- Collaborates with the multidisciplinary HHOME and Street Medicine teams in the development and implementation of complex care plans, including appropriate and timely follow up for transitions of care from acute care settings.
- Provides patient education on a variety of topics (e.g. HIV, diabetes, hypertension, asthma, nutrition, and other specific diagnostic procedures).
- Provides team-based medical management according to defined algorithms for patients with chronic diseases.
- Provides wound care services under supervision of providers and per clinical protocols as part of the Street Medicine and HHOME teams.
- Performs initial and continued assessment of client health status, immunizations, and TB screening based on established protocols.
- Administers adult immunizations, medications, and phlebotomy consistent with current guidelines and established protocols in both traditional and street settings.
- Assists with medication adherence support.
- Coordinates treatment plans/procedures for routine services such as pre-exposure prophylaxis (PrEP), drug detox, and STI treatment.
- Evaluates and executes routine refills and helps navigate prior authorizations according to established workflows for Street Medicine and HHOME patients.
- Runs HHOME drop-in clinic, including patient triage, rooming, flow, and direct nursing care.
- Participates in Street Medicine drop-in clinic as needed at the discretion of the Street Medicine team.
- Attends weekly multidisciplinary HHOME and Street Medicine team case conferences, prioritizing high-needs patients to be seen by each program.
- Works with clinical collaborators at local hospitals and community partners to connect unhoused people with the Street Medicine team and develop patient-centered care plans for patients engaged in the program. Collaborates with these same partners on transitional care plans for HHOME or Street Medicine patients accessing services at these sites.
- Documents appropriately in the electronic medical record, including weekly patient HHOME assessments.
- Uses multiple electronic data sources to gather patient information and track ED or inpatient utilization across care systems.
- Responds to medical emergencies in a timely fashion with clear delegation to clinic staff as appropriate.
- Provides culturally and racially competent client care in a manner that is both non-discriminatory and non-judgmental.
- Communicates effectively with clients/patients, clinic staff, the public at large and departmental staff in a non-discriminatory manner.
- Covers clinical job duties of non-licensed staff when required by clinic management.
- Links patients to appropriate internal and external medical, behavioral, and social services.
- Must be able to travel by foot around the Tenderloin neighborhood and surrounding area.
- Must be able to carry medical supplies in a backpack to patients within the community.
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