Nurse Care Manager - Temp

Job Description:

Position Summary:

HSL offers enhanced housing with services to seniors residing in its three affordable housing locations and at partner housing sites, aiming to improve the quality of life and support independent living. At its core, enhanced housing with services is a proactive approach wherein resident services staff regularly and actively reach out to each resident to engage with them around their health and wellness, identify areas of need/risk, and provide intensive, individualized case management and support as needed and desired by the resident.

The Nurse Care Manager is a key member of the housing team, working to support residents in living independently and safely for as long as possible by developing meaningful relationships with them and providing holistic support. The Care Manager works closely with other team members to: engage residents in wellness assessments and health education programs, connect residents to needed services, triage resident issues, provide a wide variety of case management tasks including coordinating care for residents returning home from hospital and/or rehab stays, ensure that all interventions are documented and tracked, and partner with community provider organizations.

This is an in-person role, in low-income independent living, 4 different buildings part of Brookline Housing Authority, visiting residents in their units, care coordination, evaluation, referrals, not hands-on.

No nights/weekends/holidays, business hours

Core Competencies:

• Commit to the organization's core values of respect, dignity, and empowerment.

• Able to form collaborative and trusting relationships with residents, families, and other staff.

• Work collaboratively with colleagues, both within and outside the HSL continuum.

• Listen attentively; speak respectfully; maintain confidentiality.

• Provide the highest quality of preparation and presentation.

• Committed to active outreach to residents, including engaging with them in their apartments, during programs, during meals, etc. Being 'out and about', visible and connected.

• Actively promote respect and inclusion for all residents and staff in a multicultural community.

• Have a "can-do" service mentality.

• Accept responsibility for all tasks assigned.

• Work independently toward achieving program goals

• Partner with the wellness coordinator and the resident services team to provide comprehensive case management services to residents.

• Provide regular preventative outreach to all residents to check in on their needs and overall health, and develop trusting relationships with residents and their families.

• Conduct wellness assessments of residents to determine risk and needs. Actively follow up on all identified needs, including finding resources, making referrals, and ensuring residents are actively engaged in services.

• Evaluate resident medical concerns and support residents with decision making re next steps, e.g., calling PCP, going to urgent care, going to the ED, or seeing a specialist.

• Coordinate with primary care physicians and specialists, hospitals, mental health, and other community providers. Ensure effective communication around changes in status, transitions, and service utilization.

• Active follow-up on all hospitalizations, rehab stays, and emergency room visits. Work with families, hospitals, rehabs, HSL Home Care, and/or VNA, ASAP's and other providers to ensure safe discharges and ongoing services.

• Follow up regularly with at-risk residents to support adherence to health and wellness-related activities, medication,n and treatment plans.

• Conduct and/or coordinate group and individual education sessions on health and wellness, including medication management.

• Track residents with special needs, such as dementia and mental health, and make appropriate referrals.

• Utilize collected data to identify, plan, schedule, and implement focused programs, such as falls prevention.

• Support and educate housing staff members about common medical conditions and how to identify and communicate status changes.

• Participate in resident services team meetings, provider meetings, and individual family meetings.

• Assist residents and…