Registered Nurse (Community Health)

Community Health Nurse

Under general supervision from the Community Health Services Manager in the Health Services Division of the Health & Human Services (HHS) Department, provides community health nursing services to SRPMIC Community Members with the goals of promoting and restoring health to the Salt River Pima-Maricopa Indian Community, fostering wellness and healthy living and addressing health disparities through community-driven initiatives at River People Health Center. This job class is treated as FLSA Exempt. This is a driving position.

Essential Functions: Essential functions may vary among positions and may include the following tasks, knowledge, skills, abilities and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

Examples of Tasks

Assessment

1. Monitor and promote health outcomes for referred and enrolled clients in the community health program
2. Identify community health problems through comprehensive in-home assessments from a biopsychosocial perspective to support chronic disease management, decrease unnecessary emergency room utilization, and support patient adherence towards self-management.
3. Create in collaboration with the client and intervention plan to address individual, health, safety and quality needs towards health and disease management.

Direct Care

1. Provide direct care to patients and vulnerable populations who may not have access to health care or cannot afford medical services.
2. Provide in-home treatment and support services to individuals and families who need them. This can include:

• Medication reconciliation, education, and medication administration.
• Diabetes education and glucose monitoring
• Wound care and dressing changes under the direction of WOCN plan of care
• Injection administration under existing plan of care
• Tube feeding education and support.
• Catheter education and support
• Tracheostomy education and support
• Medication Management
• STI medication management and education

• Provide counselling and education on chronic diseases including but not limited to obesity, diabetes, hypertension, congestive heart failure, and chronic kidney disease.
• Support client self-monitoring and engagement in their health outcomes
• Provide information on disease prevention.

Care Coordination & Treatment Plan Management

1. Collaborate with the interdisciplinary team including the client's medical provider for care delivery, treatment planning, and treatment goals.
2. Identifying opportunities in collaboration with the client and family members where community health worker (community health representative) services are needed for health monitoring and social determinants of health mitigation.
3. Provide ongoing evaluation of client's condition and progress.
4. Provide ongoing follow-up, basic motivational interviewing and goal setting with patient/s families.
5. Seek out opportunities to work with various teams to investigate and identify Community health needs.
6. Collaborate with public health nursing regarding data trends and high risk areas to individually support at risk clients.
7. Document and report activities accurately and in a timely manner, consistent with plan of care in client's electronic medical record.

Community Health Promotion

1. Develop strategies that support individual, family, and Community health efforts.
2. Initiates preventative health measures within the scope of practice for a professional Registered Nurse (RN).
3. Initiates appropriate interventions according to health care priorities identified in individual and Community assessments.
4. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
5. Work with providers and services within the SRPMC and outside the Salt River to improve the health of individuals and the Community as a whole.
6. Connect those who don't have access to care with direct health care services, such as screening services, preventative care, medical specialty, social work, behavioral health, convalescent, and rehabilitative services.
7. Provide health-related instruction to individuals, families, and groups.
8. Coordinate programs, services and other activities to implement targeted health promotion and disease prevention activities.
9. Present health-related instruction at conferences, staff-meetings, Community events, and to Community leaders and stakeholders.
10. Educate individuals one-on-one as needed for situations when group education is not appropriate.

Professionalism

1. Manage assigned caseload of patients and ensure to SRPMIC River People Health Documentation standards.
2. Maintain HIPAA compliance at all times.
3. Maintain organization skills to handle multiple priorities while remaining professional.
4. Ensure appropriate standards for telephone and communication methods with clients and interdisciplinary team.
5. Maintain safe and healthy working environment and uses safe work methods and procedures in accordance with program standards.
6. Participate as a member of multi-disciplinary consultation and review teams for case assignments to develop strategies and referrals that support individuals and families/caregivers in achieving healthy state.
7. Update professional knowledge and proficiency in nursing through continuing education, staff meetings, training and conferences, etc.
8. Must retain Arizona Licensed Nursing Assistant in good standing.
9. Performs other job-related duties as assigned to maintain and enhance program mission and operation.

Knowledge, Skills, Abilities, and Other Characteristics:

• Knowledge of the history, customs, culture, traditions and government of the Salt River Pima- Maricopa Indian Community.
• Knowledge of medical, behavioral, public health, and social service resources available to Community members including, but not limited to, Indian Health Service (IHS), Medicare, Medicaid, ALTCS, SSI, etc.
• Knowledge of assessment, diagnostic, preventative and therapeutic procedures used in a community health program.
• Knowledge of federal, state and SRPMIC laws and regulations governing professional nursing practices.
• Knowledge of theory, principles and scope of practice for a professional Registered Nurse.
• Knowledge of theory and practices of management in nursing services.
• Knowledge of counseling theory and techniques as well as learning principles and strategies.
• Knowledge of health systems and disease processes.
• Knowledge of data collection and analysis.
• Knowledge of public health practices and concerns.
• Skill observing, assessing and documenting the behavior and progress of patients.
• Skill assessing client needs and developing care plans.
• Skill applying professional Nursing methods and techniques as well as emergency medical procedures including First Aid and Basic Cardiac Life Support.
• Skill with verbal and written communication and the ability to communicate effectively with a wide range of people, clients, families, community groups and health professionals.
• Skill maintaining accurate records and compiling timely reports.
• Skill with program planning.
• Ability to establish and maintain positive and effective working relationships with colleagues, subordinates, supervisors, health care professionals, Tribal officials, representatives of resource agencies, patients and Community members.
• Ability to work as a productive member of a team.
• Ability to deal with sensitive issues and maintain appropriate, professional and confidential relationships.
• Ability to incorporate cultural differences, health beliefs and learning styles.
• Ability to develop and implement program protocols as well as identify and address programmatic problems.
• Ability to use a personal computer and related software, including Microsoft Office along with a variety of standard office equipment including cellular phones, photocopiers, FAX machines and calculators at an intermediate of expert level.
• Ability to bend, lift, and move in a manner consistent with the duties assigned.

Minimum Qualifications

• Education: An Associate Degree in Nursing from an accredited college or university and certification as a Registered Nurse (RN) required. Bachelor's degree preferred
• Licensure: Current license to practice as a Registered Nurse in the State of Arizona required.
• Experience: Three (3) years professional Nursing experience required. At least one (1) year experience in Public Health or Home/Community Health Nursing preferred. Experience working with Native Americans preferred. Working knowledge of public health, infection control, immunizations, diabetes education and chronic disease management preferred.
• Equivalency: Any equivalent combination of education and experience that will allow the applicant to satisfactorily perform the