Mobile Nurse Care Manager
Philadelphia, PA, USA
Tuesday, July 28, 2020
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 patients seen through Project HOME’s Homeless and Residential Programs and the Hub of Hope.
All locations serve adults who are homeless, may be seeking recovery from dependence to substances, and who may also have a co-occurring mental illness. Principle roles include:
- Serve as a key member of an integrated Mobile Team and instrumental to its success.
- Serve as the care coordinator between the patient, primary care team and other providers, including street outreach or residential case managers, insurance-based case managers, mental health intensive case managers (ICMs), medical, dental and behavioral health specialists, hospital-based service providers, and others.
- 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.
- Assess, triage and respond to patients with acute, chronic, and preventive health and wellness needs at Entry Level Sites and the Hub of Hope.
- Provide medical/nursing support and consultation to staff and residents of Entry Level Sites and other Residential locations as requested by Clinical Leadership. *Requires movement between sites.
Essential Duties and Responsibilities
- 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 staff and residents on health-related topics and activities that enhance recovery and self-care management.
- 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).
- 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
- First aid
- Review monthly Residential medication room audits in accordance with PH med monitoring policy.
- Provide staff training and education to ensure proficiency with medication monitoring, as well as other topics critical to management of the target population.
- Wound care
- Facilitate vision screenings and assist patients with obtaining corrective eyewear.
- Explore options for other on-site healthcare services including podiatry and vaccinations in collaboration with the Philadelphia Department of Health.
- In collaboration with Hub of Hope Medical Team, Residential staff, and hospital providers, assess for and facilitate admissions to Serenity Court Homeless Medical Respite.
- 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.
- Facilitate scheduling of appointments & procedures such as colonoscopies, biopsies, radiology studies, chemotherapy, lab testing, medical/dental/psychiatric evaluations and other health-related activities.
- Obtain prior authorization for medications, procedures, or other services as needed.
- Provide guidance to Residential 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).
- Maintain nursing licensure and CPR certification.
- Inputs all required care management data into EHR.
- 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.
- Maintains own training, certification, and continuing education activity log for reference at mid-year and annual performance reviews.
- Bachelor of Science in Nursing (BSN)
- Active RN license in Pennsylvania
- BLS certification
- 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.