RN Community Outreach Care Coordinator

Job Description

Job Description

SUMMARY: The Float RN provides direct clinical care and patient care coordination for culturally-diverse populations in the medical clinic as well as in the community alongside the Harm Reduction Team. This role is primarily responsible for providing flexible coverage for a variety of clinic nursing roles as needed, possibly including mobile nursing, infectious disease, maternal-child health, and primary care. The role will consistently serve people experiencing barriers to healthcare, including homelessness and substance use, by emphasizing trauma-informed care and harm reduction principles. Through strong collaboration with an interdisciplinary team, the Float RN is a key team member in supporting patient continuity of care.

DUTIES AND RESPONSIBILITIES:

• Professional Clinical Care and Clinic/Outreach-Based Care Coordination

• This position will flex between clinical programs and provide back-up nursing care.  Care delivery may include:

• Deliver skilled interventions including, but not limited to, wound care and assessment, foot care, medication and vaccine administration, phlebotomy, education, standing orders, minor procedures if appropriate, and vital signs. 
• Conduct nurse-led or provider-level visits through the utilization of standing orders.
• Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.
• Utilize harm reduction strategies to address health concerns disproportionately affecting unhoused populations including HIV, hepatitis C, STIs, wounds, foot health, asthma, diabetes, substance use disorder, overdose risk, and behavioral health concerns. Provide harm reduction services including naloxone trainings, syringe and safer use supplies, and harm reduction education.
• Coordinate care for prenatal, perinatal, postpartum, newborn, infant and pediatric patients.
• Facilitate rapid access to OB care, HIV and hepatitis C care, PrEP, PEP, and MOUD for substance use disorder. 

• Provide professional clinical care (including triage, assessment, intervention, evaluation) in varying community settings, as well as in the fixed-site clinic, prioritizing trauma-informed care principles and patient-led care plans. 
• Perform assessments of patients’ unmet medical, behavioral, and social care needs and support the care team in meeting these needs. Help patients navigate community resources and specialty care, as well as linkages to primary care when needed. Work to reduce barriers through follow-up, transportation support, appointment reminders, and other strategies. Provide advocacy on behalf of patients seeking outside care.

• Work collaboratively with clinic staff to identify high-risk or out-of-care individuals. Offer mobile care coordination services and linkages to care as appropriate. 
• Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol. 
• Read and interpret patient charts and lab results.  Review new labs and identify need for follow up. Communicate with other clinical providers as needed.
• Assist patients in care transitions, such as entering or discharging from treatment, hospitalizations, respite programs, and shelters. Work with external service providers to ensure continuity of care.
• Support care plan and medication adherence through medication set up, delivery, and routine lab draws. 
• Perform clinical exams in clinic and outreach environments.

• Program Implementation

• In collaboration with other Outreach, Medical, and Harm Reduction staff, implement policies and procedures to support mobile health services utilizing evidence-based practices and patient-centered care models.
• Participate in program development and implementation with other clinic teams, including maternal-child health and medical nursing.
• Develop relationships with community organizations and individuals to ensure collaboration and partnership to advance program goals. 
• Communicate frequently and directly with team members on patient needs and direction of daily work and larger issues affecting the health status of homeless individuals. 
• Utilize staff teams within NACC to refer clients appropriately, including but not limited to the patient advocate, population health, MAT services, infectious disease treatment, and other teams.
• Initiate and lead targeted ‘in-reach’ and outreach to engage, educate, refer, and connect out-of-care patients to integrated health care services.
• Document data, plans, clinical actions, client progress, response to care and other relevant patient information in EHR.

SUPERVISORY RESPONSIBILITIES:

• Does not directly supervise staff.

QUALIFICATIONS:

• Active and unrestricted Registered Nurse license in the State of Minnesota.
• Public health nurse registration preferred.

• Clinical experience in community health and outreach-based nursing. 

• Experience working with chemically dependent adults and knowledge of harm reduction principles
• Excellent verbal and written communication skills.
• Commitment to excellence and high standards.
• Strong organizational, problem-solving, and analytical skills; able to manage priorities and workflow.
• Ability to work independently and as a member of various teams and committees.
• Acute attention to detail.
• Ability to deal effectively with a diversity of individuals at all organizational levels.
• Good judgement with the ability to make timely and sound decisions
• Demonstrated ability to plan and organize projects.
• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.

COMPETENCIES:

• Problem Solving--Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Diversity--Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
• Ethics--