Clinical Duties – Approximately 60% Time - Effectively triages patients with appropriate attention to acuity and the availability of medical providers for urgent care evaluation.
- Provides and completes medical treatment as ordered and performs procedures based on MNHC Nursing Protocols.
- Completes/ensures completion of nursing co-visits in conjunction with medical providers.
- Will be responsible for prescription refills and assist medical provider with other clinical case management documentation and follow up.
- Regular communication, client advocacy and case conferencing with the client's primary and specialty medical providers.
- HIV Rapid initiation and re-engagement to care.
- Provide nursing interventions and education about a variety of issues, as appropriate to both client-assessed need for intervention and the nurse's trained skills. Interventions may include:
o Healthful living habits
o Safer sex practices
o Prevention of exposure to opportunistic pathogens
o Information and education on preventative care
o Needed immunizations
o Managing a long-term chronic illness
- Referral and follow-up for medical evaluation and treatment.
- Education and counseling about HIV disease process management.
- Case management of HIV medication therapy including monitoring and educating client about medication side effects, disease process, and lab values.
- Adherence assessment and interventions to include counseling, education, and referral, as appropriate.
- Nutritional assessment and interventions to include counseling, education, and referral, as appropriate.
- The Nurse will be responsible for identifying needs for interventions and facilitating the client's ability to access recommended interventions and will either directly provide the intervention or will refer the client to an appropriate resource to receive the intervention.
- Documentation in progress notes, on the required forms and in the Electronic Health Record.
- Assists in the coordination of clinic operations, flow, and client care. Completes documentation of reports and clinical services provided with a high level of detail and thoroughness.
- Assists the HIV Clinical Operations and Integration manager in developing, implementing, and evaluating best practices, protocols, policies, and procedures.
- Ensures Confidential Reporting is submitted to the Department of Public Health and addresses any submission issues.
- Laboratory Testing Personnel Backup: Perform moderate lab testing, and Provider Performed Microscopy per the laboratory guidelines.
Care Management – Approximately 20% Time - Conduct outreach to eligible and referred patients for care management, via phone or in-person.
- Participate in Care Conferences with patient, family members as needed and patient’s Care Team.
- Interface with other Departments in co-managing patients and participate in inter-departmental projects.
- Develop patient-centered, individualized Care Plans for our most medically vulnerable clients:
- Assess clients for ability to attend all medical appointments including primary care visits, procedures, imaging and specialty visits.
- Actively address barriers to attending medical appointments.
- Support client in attending all medical appointments. This may include collaborating with other agencies, arranging transport, phone call reminders or arranging for the patient to be accompanied to the visit.
- Provide regular medication reconciliation with clients. Assess adherence and develop continuous follow up plan for medication non-adherence.
- Provide meaningful telephone follow up after hospitalizations and link patients to appropriate medical follow up care.
- Assess clients for the need of a home visit, and provide home visits as needed to those that would benefit.
- Support identification of patient’s strengths and barriers to ensure optimal and successful Care Plans. Respect patient health choices in the Care Plan process.
- Track barriers to care, assist with eliminating or reducing barriers to obtaining needed services.
- Collaborate with patient to navigate the system of providers and social service agencies.
- Support Nurse, patient and caregiver(s) in re-assessment of Care Plan goals.
- Connect patient to cultural, community, housing and social resources, and follow-up to assure connections are made whenever possible
- Act as a liaison to hospitals, long-term care settings, specialists, home health representatives, and other community agencies in collaboration with Nurse.
- Facilitate care transitions for patients discharging from external facilities (i.e. skilled nursing, hospital, and emergency room) and ensure appropriate follow-up with patient’s PCP in a timely manner.
Administrative Duties – Approximately 20% Time - Attend weekly multi-disciplinary team meetings and present clients’ psychosocial assessment and treatment plan based on recommendations from physician, health educator, nutritionist, and other team members. Participate in staff meetings and in-service training. Participates in and attends nursing staff meetings. Receive weekly individual clinical supervision.
- Attends and actively participate in Care Management/Health Homes Team meetings, Care Team Huddles, and assigned meetings and/or trainings.
- Provides input and shares creative strategies to improve the Care Management/Health Homes Program.
- Completes all required documentation in a timely fashion in accordance with regulations, funder requirements, program standards and workflows.
- Documentation of interventions in clients’ records.
- Make community presentations of HIV Services.
- Other duties as assigned.
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