||JOB SUMMARY: The Northwest Regional Council, as an Area Agency on Aging, funds and/or provides community-based programs to help elders and people with disabilities live in their own homes and communities for as long as possible, postponing or eliminating the need for institutional care. The Nurse Care Coordinator will provide both intensive care coordination and comprehensive case management and having documented results in improved health outcomes for a caseload of clients enrolled in NWRC’s Health Home Program. This position will use health screening/assessment tools, health education, and evidence-based practices to help clients
establish health action plans and will provide ongoing support to assist clients to achieve established health goals. In addition, this position provides nursing services activities upon referral. This position will be sited out of the Burlington (Skagit County) office with a client caseload consisting of residents from Skagit County and the northern parts of Snohomish County. Nursing services coverage may include Island and San Juan Counties.
ESSENTIAL JOB FUNCTIONS include but are not limited to:
Nursing Service Responsibilities
1. Provides consultative support and/or home visits upon referral by Northwest Regional Council case managers and other program staff to assess and assist with client evaluation regarding clients’ health care needs.
2. Provides in home training to the client and care provider as necessary.
3. Responsible for maintaining current, accurate, and concise documentation of nurse activities under established policies and procedures.
4. Assists in the development of materials and approaches to help caregivers and family better understand the needs of the individual they are caring for and provide appropriate care and support.
Health Home Care Coordinator
1. Administers self-management readiness assessments which includes an evidenced-based tool that determines an individual’s level of activation in their own health care;
2. Assists client in developing a safe, appropriate and client-centered Health Action Plan that documents strategies and measurable objectives to meet health goals;
3. Administers clinical and functional tools to include depression, pain, and/or alcohol and substance abuse screenings, as well as functional impairment assessments;
4. Conducts in-person visits and accompanies clients to health provider appointments as needed, to ensure continuity of care and coordination;
5. Provides health education and coaching to assist the client in increasing self-management skills, and improve their engagement with health and service providers;
6. Fosters communication between providers (i.e., primary care provider, medical specialists, etc.) and provider networks (i.e., those authorizing behavioral and long term supports and services);
7. Facilitates and encourages client’s use of peer supports and/or participation in appropriate support groups and self-care programs in order to increase the client’s knowledge of their health
care conditions and to improve adherence to prescribed treatments;
8. Provides supportive functions for the client, including client advocacy, assistance, consultation, family support, and crisis intervention;
9. Works collaboratively with multi-disciplinary team, including nurses, case managers, and case aides;
10.Documents in numerous electronic platforms to ensure proper record keeping per contract requirements;
11.Develops and maintains complete, concise case files in compliance with policy;
12.Develops and maintains linkages with community agencies and organizations that could give support to the program or individual older persons;
13.Attends meetings, trainings, and seminars as requested or needed for professional development.
14. Performs other duties as assigned.
WORKING CONDITIONS\PHYSICAL REQUIREMENTS: Work is performed approximately 30% in an office environment and 70% in field for client visits. Potential hazards include working with emotionally unstable, non-compliant or aggressive clients and complex family dynamics; significant travel; driving in inclement
weather; second hand tobacco smoke; aggressive animals, exposure to contagious diseases and exposure to repetitive stresses due to prolonged use of computers.
Sufficient mobility is required for the use of office equipment such as computer laptops, telephones, files and copiers as well as for performing in-home assessments of clients which may have limited accessibility. The ability to hear and communicate at a level sufficient to perform the essential functions of the position is required. Ability to lift and maneuver a maximum of 30 pounds.