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Sacred Heart Nurse Care Manager

Philadelphia, PA, USA Req #391
Tuesday, July 28, 2020

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THE MISSION OF PROJECT HOME

The mission of the Project HOME community is to empower adults, children, and families to break the cycle of homelessness and poverty, to alleviate the underlying causes of poverty, and to enable all of us to attain our fullest potential as individuals and as members of the broader society. We strive to create a safe and respectful environment where we support each other in our struggles for self-esteem, recovery, and the confidence to move toward self-actualization.

Project HOME achieves its mission through a continuum of services comprised of street outreach, a range of supportive housing, and comprehensive services. We address the root causes of homelessness through neighborhood-based affordable housing, economic development, and environmental enhancement programs, as well as through providing access to employment opportunities; adult and youth education; and health care.

Project HOME is committed to social and political advocacy. An integral part of our work is education about the realities of homelessness and poverty and vigorous advocacy on behalf of and with homeless and low-income persons for more just and humane public policies.

Project HOME is committed to nurturing a spirit of community among persons from all walks of life, all of whom have a role to play in making this a more just and compassionate society.

THE VALUES OF PROJECT HOME

The work of Project HOME is rooted in our strong spiritual conviction of the dignity of each person.

We believe that all persons are entitled to decent, affordable housing and access to quality education, employment, and health care.

We believe in the transformational power of building relationships and community as the ultimate answer to the degradation of homelessness and poverty.

We believe that working to end homelessness and poverty enhances the quality of life for everyone in our community.

We believe that the critical resources entrusted to us to achieve our mission must be managed honorably and professionally.

Job Summary: The Registered Nurse (RN) Care Manager provides a holistic, trauma informed and patient-centered approach in caring for residents living at Sacred Heart Recovery Residence (SHRR) and provides medical/nursing consultation and support to residents and staff living at St. Elizabeth’s Recovery Residence (SERR[UH3] ).  Both locations serve adults who are homeless and or seeking recovery from dependence to substances, and may also have a co-occurring mental illness. Principle roles include:

  • Serve as a key member of the SHRR residential program team and instrumental to its success.
  • Provide medical/nursing support and consultation to staff and residents of SERR. 
  • Work closely with residents, Residential Service Coordinators, Case Managers, Program Managers, other Project HOME (PH) stakeholders, Project HOME Healthcare Services (PHHS) and other primary care providers on coordinated intake assessments, goal-setting, and plans of care.
  • Serve as coordinator of health services for SHRR residents including Medication Assisted Treatment services if applicable, medical, dental and behavioral health providers, health insurance plans, and hospital-based service providers.
  • Assess, triage and respond to residents with acute, chronic, and preventive health and wellness needs at SHRR and SERR.

Essential Duties and Responsibilities

Care Management

  • For those residents requiring and agreeable to nurse care management services: coordinates with residential program staff, primary care providers, behavioral health providers, and other providers in implementing individual care plans, especially follow-up plans from ER or hospital discharges.
  • Information-sharing, goal setting with the participant, pre-visit planning and after-visit follow-up, exploring gaps in care and working to eliminate them.
  • Educating the patient and/or support system in areas such as recovery from substance dependence, disease-specific management, medication management, healthier life-style choices, stress reduction, chronic disease management, and pharmacological agents.
  • Facilitate individual or group sessions which provide education to residents of SHRR and SERR on health-related topics and activities that enhance recovery.
  • Coordinating care with intensive emphasis during critical care transition points (e.g. from hospital/ED to home, from street to housing, from specialist to primary care, from primary care to hospice.
  • At SHRR, participates in regular residential/outreach meetings for case review and discussion of evidence-based chronic disease management, integrated care best practices

 

Direct Clinical Care

  • Demonstrates clinical excellence, flexibility, patience, critical thinking/decision-making, and ability to teach and collaborate with providers and patients. Performs clinical assessments and procedures using universal precautions, aseptic technique as required, and in accordance with proper OSHA standards. Duties include, but are not limited to:
  • Vital signs including ability to interpret pulse oximetry
  • Perform AIMS assessments
  • Medication injections & immunizations
  • Venipuncture
  • First aid
  • Perform monthly medication room audits in accordance with PH med monitoring policy.
  • Ensure that all staff demonstrate competence in medication monitoring.  
  • Wound care
  • Facilitate vision screenings and assist patients with obtaining corrective eyewear.
  • Counsel patients and assess readiness to change regarding recovery, health care and lifestyle choices.
  • Assess and manage patients’ needs related to acute and/or chronic health conditions.
  • Assist patients with their recovery.
  • Provide staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population.
  • Provide guidance to SHRR staff regarding symptom assessment of residents with acute and chronic health conditions.
  • Assess the need for durable medical equipment and collaborate with PCP, medical home, insurer, pharmacy, and/or medical supply company to obtain necessary items.
  • Collaborate with Program Manager and other key stakeholders to identify areas for improvement.
  • Participate in Project HOME/PHHS Quality Improvement initiatives.
  • Attend all mandatory Project HOME/PHHS mandatory trainings and/or trainings recommended by Direct Supervisor(s).

 

Documentation

  • Inputs all required care management data into NextGen. 
  • Inputs non-medical care management notes in ETO.
  • Ensure that staff maintain current medication list and emergency face sheet in ETO.
  • Per HIPAA regulations, obtain all necessary signed written authorizations from residents to coordinate and share information with other healthcare providers, including PHHS, and Residential case managers.
  • Ensure that residents sign an annual Privacy Notice.

Minimum Qualifications

  • Bachelor of Science in Nursing (BSN)
  • Active RN license in Pennsylvania
  • BLS certification

Preferred Qualifications

  • One or more years’ experience working as an RN with the target population

 

Project HOME is an Equal Opportunity Employer

 

 


The mission of the Project HOME community is to empower adults, youth, and families to break the cycle of homelessness and poverty, to alleviate the underlying causes of poverty, and to enable all of us to attain our fullest potential as individuals and as members of the broader society. We strive to create a safe and respectful environment where we support each other in our struggles for self-esteem, recovery, and the confidence to move toward self-actualization.  Join us!  Project HOME has a long-standing commitment to equal employment opportunity for all staff and applicants for employment.  Employment decisions including, but not limited to, hiring selection, performance evaluation, administration of benefits, working conditions, associate programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.

Other details

  • Job Family Mandatory Reporter
  • Pay Type Salary
  • Philadelphia, PA, USA