Registered Nurse - LATS

Job Description

At Virginia Garcia Memorial Health Center, we honor all members of our community and acknowledge the dignity of each person we serve. Our purpose is to provide high quality, comprehensive primary health care to the communities of Washington and Yamhill counties with a special emphasis on migrant and seasonal farm workers and a view to removing barriers to health care. We strive to provide an environment that welcomes and values the people we employ and serve.

The Registered Nurse – Recuperative Care (RN‑RC) provides admission screening and intake, care planning, case management, patient education and health navigation, and clinical care within the scope of practice, for patients being discharged from the hospital setting without stable housing for recovery. This position works under the direction of a VG Medical Director with a non‑clinical employee to visit patients assigned to 10 beds within a larger homeless shelter located in Hillsboro for basic medical supervision and care coordination.

The Recuperative Care Program (RCP) is a new program in partnership with Washington County Supportive Housing Services and Greater Good Northwest to provide acute and post‑acute care specifically for people experiencing homelessness who are too ill or frail to recover from an illness or injury on the streets or in emergency shelter, but who do not require hospital‑level care or skilled nursing services.

This position will be based out of the VG 7th Ave clinic and will require travel to the RCP program site in Hillsboro and may require travel to local hospitals for discharge planning.

• Screen referrals from hospitals and coordinate with discharge planners to assess patient acuity, program requirements, and bed availability to determine appropriateness for RCP admission.
• Identify potential clinical and supportive service needs while within respite program.
• Proactively communicate with RCP participant’s primary care team (VG or external) to facilitate early post‑hospital contact.
• Obtain required consents and releases for coordination of care.
• Develop care plan based on patient goals and the reason for admission to RCP.
• Gather information for a clinical care plan including physical and psychological history and assessment; list of current medications, dosages, and allergies; vital signs; other pertinent information, such as laboratory or other test results.
• Identify discharge indicators and develop a discharge plan with patient.
• Participate in and facilitate multi‑disciplinary care coordination meetings with appropriate providers (e.g., PCP, home health, pharmacies, specialty care).
• Coordinate with shelter case management to address SDOH and other non‑clinical needs.
• Provide shelter staff education and support around basic medical knowledge as relevant for evening and weekend supervision of RCP residents.
• Huddle daily with RCP team to create and implement daily action plans, performing transition of care visits for patients being discharged from hospitals, following up with outside provider recommendations after outpatient visits and ensuring that treatment recommendations and medication changes are acknowledged and actualized.
• Facilitate patient access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies (as needed).
• Provide patient education and health coaching on topics including diabetes, hypertension, and other chronic diseases, including assisting patients with self‑management goal setting.
• Educate patients on how to utilize after‑hours number or daytime nurse triage to address immediate clinical needs and provide guidelines for when to contact RCP team or PCP vs. seeking emergency department care.
• Log vital…