Nurse, Community Health

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

Provides support for clients, which includes coordinating an array of services designed to improve the health of high‑needs, high‑risk clients. Care coordination responsibilities will include assessment, care planning, monitoring of client status and implementation and coordination of services. Provides support to clients 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.

This position is not a direct care provider of intermittent or emergency nursing care, skills or services requiring physicians' orders and supervision.

Provides support for clients, which includes coordinating an array of services designed to improve the health of high‑needs, high‑risk clients. Care coordination responsibilities will include assessment, care planning, monitoring of client status and implementation and coordination of services. Provides support to clients 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 coach the client to build confidence and competence in four conceptual areas, or "pillars": medication self‑management, use of a patient‑centered health record, primary care and specialist follow‑up, and knowledge of red flags of their condition and how to respond.
• 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.
• 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…