RN Health Promotion Nurse

CORE VALUES

The core values of Community Health Center of Southeast Kansas, Inc. (CHC/SEK) are dignity and stewardship. Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of the Center's resources.

The Health Promotion Department works to improve health outcomes, reduce the overall cost of care, and improve the patient experience within identified patient populations. These populations are identified through advanced healthcare analytics, quality metrics, and provider and care team referrals.

The Health Promotion Nurses are motivated and passionate about improving health outcomes of patients. They strive to understand, motivate, and help our patients achieve their goals in health and wellness by building rapport, eliminating barriers, collaborating with patients to set goals, and working within a multidisciplinary care team. This position is responsible for outreaching to patients who were recently discharged from an inpatient stay or emergency department visit.

To do this, the Health Promotion Nurse must be flexible, knowledgeable about disease processes, community resources and CHC/SEK care systems, and be able to address barriers to improve health outcomes.

• Engage assigned patients and work to decrease the impact of exacerbations on health and accelerate recovery through targeted care management. Provide coordination of care within an interdisciplinary team that further supports retention, wellness, and overall health.
• Implement ongoing care management services to promote continuity of care, which may mean working with the same patient for an extended period of time.
• Create and periodically update patient specific care plans that include clear goals, priorities, and realistic actions to achieve their goals. In addition to goal setting, care plans include performing medication reconciliations, obtaining complete medical history, health risk assessments, and preventive and behavioral health screenings.
• Support care plan progress by scheduling annual exams and follow-up appointments, scheduling transportation, arranging prescription coordination, and/or other preventive care services, as needed.
• Use skills like motivational interviewing and shared-decision making to engage patients in the development of health and social support goals, coaching patients in the effective management of their health conditions and utilizing self-care techniques.
• Monitor for and review discharge notifications and information provided in EHR reports and payer portals. Collaborate with outside facilities to obtain timely discharge records and needed information.
• Contact patients that have been recently discharged from an inpatient and emergency department settings to evaluate their status, complete a medication reconciliation, arrange any needed follow-up care, and to ensure a smooth transition back to primary care.
• Assess for potential social determinants of health, evaluate patients for chronic care management services, connect with community and organizational resources, and discuss with patient’s provider, as appropriate.
• Communicate necessary information to patient, provider, care team and other staff through clear and concise documentation.
• Provide chronic disease education so patients understand more about their chronic conditions, related medications, and treatment plans.
• Utilize resources (e.g. accountable care organization (ACO) data/informatics), technology, and telehealth platforms to better connect patients to care and provide nursing assessments, as needed.
• Contribute to and utilize data to achieve program goals and improve patient health outcomes.
• Help maintain…