RN Outreach Case Manager

Job Description

Job Description

SUMMARY : The Community Outreach RN will provide direct clinical care and patient care coordination in the community alongside the Harm Reduction Team, as well as in the medical clinic. Within NACC’s clinical outreach program, this role will provide preventive health and acute care services within a mobile unit and in other outreach settings, serving people experiencing barriers to healthcare including homelessness and substance use. This role will also emphasize linkages between outreach and clinic settings, and the delivery of trauma-informed care across both spaces.

DUTIES AND RESPONSIBILITIES :

• Professional Clinical Care and Clinic / Outreach-Based Care Coordination
• 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.
• 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.
• Perform assessments of patient’s 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.
• Facilitate rapid access to HIV and hepatitis C care, PrEP, PEP, and buprenorphine for substance use disorder.
• Support care plan and medication adherence through medication set up, delivery, and routine lab draws.
• Performs clinical exams in clinic and outreach environments.
• Outreach 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.

SUPERVISORY RESPONSIBILITIES :

QUALIFICATIONS :

Clinical experience in community health and outreach-based nursing.