Nurse, Community Health

Registered Nurse (RN) – Home Health Registered Nurse

Department of Human Services. Hourly Wage: $36.11‑$40.64/Regular/Full-Time.

Provides support for clients, coordinating an array of services designed to improve the health of high‑needs, high‑risk clients. Care coordination responsibilities include assessment, care planning, monitoring client status and implementation and coordination of services. Provides support for effective care transitions, improved self‑management skills and enhanced client‑provider communication. Will facilitate interdisciplinary consultation, collaboration and care continuity across care settings. Offers clients, providers and case managers with health‑related assessment consultation in order to enhance the development and implementation of the client’s plan of care for TXIX and Home & Community Case Management.

Will perform case management duties and carry a caseload.

• Coordinates follow‑up activities and referrals with other programs including the Family Caregiver Support Program and HCS Medicaid Case Management.
• Provides health‑related assessment and consultation in development of the plan of care through the CARE Tool to case managers.
• Completes Skin Care Protocol based on the ALTSA Long Term Care Manual.
• Identifies and addresses barriers to overcome and impediments to accessing health care and social services.
• Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient‑centered, goal‑oriented Health Action Plan.
• Assesses activation level for self‑care through use of the Patient Activation Measure® (PAM®).
• Provides evidence‑based health assessments and screenings such as BMI, PHQ‑9, Katz ADL, PSC‑17, GAD‑7, AUDIT or DAST.
• Provides transition support services that coaches the client to build confidence and competence in four conceptual areas, or “pillars.”
• Works with supervisors and other health care providers, hospital discharge planners, skilled nursing facility staff, and staff at the client’s health home to implement services and analyze the disposition of cases.
• Performs facility visits, home visits, and follow‑up telephone calls to develop critical coaching relationships, to empower clients to take an active and informed role in their discharge planning.
• Coordinates and communicates regarding the client’s post‑discharge status with all involved health care providers including, but not limited to: primary care, mental health, specialty care, and pharmacy.
• Identifies and addresses barriers to overcome impediments accessing health care and social services.
• Provides referrals and advocacy for clients and their caregivers to community‑based services and supports which includes family caregiver programs, nutrition programs, in‑home care and case management.
• Provides teaching about self‑management of the client’s chronic health condition and provides resource links to ongoing chronic disease self‑management support services.
• Develops and maintains complete and concise client files in compliance with policy to appropriately document activities performed for the client and all elements required for specific programs.
• Maintains all required documentation related to services provided and conforms to monthly deadlines.
• Participates in staff meetings, public education and provider training sessions, as appropriate.
• Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.
• Prepares correspondence, memos, and client‑related written materials, as appropriate.
• Participates in continuing education and training programs.
• Works collaboratively with multi‑disciplinary teams involving nurses, case managers and case aides.
• Attends required meetings and trainings.

• Knowledge of the long‑term care system and services, issues related to aging and disability, and case management.
• Knowledge of local in‑home and community options and resources for the elderly and adults with disabilities and their caregivers.
• Knowledge of…