Community Health Nurse- Jamaica Plain - Partners HealthCare System : Job Details

STAFF NURSE AMB/ 40 HOURS/ ROTATING SHIFT/ BWH- JAMAICA PLAIN- SOUTHERN JAMAICA PLAIN HEALTH CENTERABOUT SOUTHERN JAMAICA PLAIN HEALTH CENTER

Southern Jamaica Plain Health Center (SJPHC) is a licensed Health Center of Brigham and Women's Hospital and provides multi-disciplinary, comprehensive care including Adult and Pediatric Primary Care, OB/GYN, Cardiology, Neurology, Podiatry, and Behavioral Health. Each year, more than 12,000 patients from Jamaica Plain and surrounding neighborhoods of Boston use these services, producing more than 40,000 visits to SJPHC. The health center's services are provided by a bilingual English/Spanish, and other languages, medical and professional staff. SJPHC has a long-standing commitment to comprehensive team-based care. SJPHC is a teaching site for Harvard Medical School and multiple professional, university, and high schools.

SJPHC is widely known for its social justice approach and its extensive programs and offerings related to Racial Justice and Health Equity. These include programs for staff, adults, and youth; and training provided to local, state, and national organizations. SJPHC's Health Promotion Center, adjacent to the health center offers numerous exercise programs, educational groups, and community programs. Together these programs and services are designed to address the health of the whole person, family, and community, addressing the immediate needs of patients, and thinking upstream about how to address the social factors and processes - including racism - that impact the health of our patients.

GENERAL SUMMARY:

The Primary Care Registered Nurse is an important member of the primary care multi-disciplinary healthcare team. Patients/families and the health care team work best as partners with shared goals for attaining optimal health and wellness. The RN is integral to providing the support and care necessary to achieving such goals. The primary responsibility of the staff RN is to provide excellent care for patients and families. The role requires the provision of care that is comprehensive, compassionate, delivered to patients of all ages, working with a diverse, medically and socially vulnerable population. Role responsibilities within this setting are defined below.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1 . Patient Care Organization

* May perform all duties as described in the Brigham and Women's Registered Nurse Job Description to meet direct care requirements of the role.

* Functions effectively and safely within the scope of practice of the Registered Nurse: recognizing limitations of the role and knowing when to seek assistance/guidance of the LIP. Willing to work within scope to strengthen the practice and provide patient centered care.

* Provide culturally sensitive, patient-centered care of the highest quality to patients of all races, ethnicities, backgrounds and income levels.

* Triages all urgent calls and assists with walk-ins or patients that become acutely ill during the office visit. Sets priorities when organizing care based upon the acuity of urgent calls. Is aware of clinic flow and re-arranges provider schedules to accommodate the urgent care needs

* Assesses the care needs of patients with routine and chronic illness. Develops, implements and re-evaluates an individualized nursing plan of care (PoC)

* Within a multi-disciplinary team, assists patients with pre-existing conditions to achieve lifestyles changes that promote a healthy mindbodyspirit.

* Uses a variety of modalities to engage patients including nurse visits, telephonic and electronic communication (Gateway/Telehealth)

* Operating from a Human Caring framework, implements a wide range of interventions/skills including coaching, education, counseling, motivational interviewing, referral and advocacy to services and resources as appropriate to promote health and wellness

* Evaluation and documentation of disease management impact; works closely with clinical team and family to promote self-management and ensure a cycle of continuous refinement of PoC which includes education for the patient and family, utilizing appropriate resources.

* Demonstrates awareness of community resources and assists staff, patients, and families to effectively utilize them.

* Ensures coordination of care across the care continuum including; home care, outpatient clinics, emergency/urgent care and hospital settings using clear, concise communication and documentation in the EHR.

* Knowledge base should include basic health teaching, family planning education, how to care for common pediatric and adult illnesses.

* Facilitates the advanced care planning process, assisting patients and families to consider options and goals for future healthcare decisions. Documents advanced care goals in the EHR.

* Works with Population Health Coordinator and Primary Care Providers to develop and implement interventions targeted at patients not meeting metrics (e.g. HgbA1c control, Blood pressure control, etc)

2. Team Based Care

* Willing to educate and mentor clinical support staff as needed. Able to delegate safely and effectively to support staff tasks that are within scope of practice.

* Provide care management and coordination across the primary care team for aging, chronically ill, those with increasingly complex health needs; strategically providing care with team members functioning at the top of their license/responsibilities.

* Evaluates effectiveness of care given by multi-disciplinary care team, identifies problems and guides members toward solutions promoting health.

* Facilitates the improvement of patient's ability to self-manage prevention and behavioral health issues and placing emphasis on transitional care, prevention, and wellness.

* Communicates effectively and clearly with members of the care team regarding patient status and needs.

* Backs up floor nurse as needed for required medication and vaccine administration

3. BWH Professional Practice Model Qualities

Nurses as Authentic Leaders: Serves as a resource person to other members of the team around the care needs of patients and provides support to other members of the clinical and administrative team in an accessible, open manner. Is an active participant in cared delivery and shared decision making.

True Collaboration: Engages with enthusiasm in process improvement activities, piloting of new workflows, willing to embrace change and thrive in an environment of continuous process improvement. Open to feedback and ongoing learning. As part of this process, the RN is able to demonstrate skilled respectful and effective communication.

Meaningful Recognition: Is committed to enhancing their individual professional growth and development by participating in activities that foster a commitment to achieve and sustain quality and safety outcomes for patients. This includes participation in the process of consistent and ongoing peer feedback/meaningful recognition; promoting a culture of continued improvement and learning for themselves and their nurse colleagues.

Scholarship: Supports and participates in innovation and lifelong learning for self and others: contributing to a culture of evidence informed practice.

Relationship Based Care: Participates in BWH's Caritas culture which transforms the relationships institution wide. This creates an environment that promotes healing by recognizing the humanity of providers and patients and families. The nurse is responsible for knowing and caring for him/herself so that s/he can own an open, caring, and intentional way of being with and caring for patients and families. The nurse works to create a healing environment by potentiating wholeness, beauty, comfort, dignity and peace.

Outcome Focused Measures: Nurses should be engaged in using science and evidence-based practice to identify and develop indicators of high quality and reliable nursing care. This results in a practice that nurses can establish and articulate how indicators impact the vision and goals of the organization.

4. Participatory Management of Fiscal Responsibilities

* Utilizes time and materials in an effective and economical manner.

* Provides suggestions which support the delivery of cost-effective healthcare to patients and families.

* Assesses patient's acuity accurately when making decisions regarding clinical bookings, appropriate level of service and staffing.

* Is familiar with accountable care regulations and demands.

QUALIFICATIONS:

Education:

* Graduate of an approved school of nursing with current registration in Massachusetts. For newly licensed nurses a Bachelor of Science Degree in Nursing is required.

* Current license to practice as a registered nurse in the State of Massachusetts required.

Experience:

* Three to five years Primary Care experience preferred.

* Telephone Triage experience preferred.

* Experience with Adult and Pediatric patients preferred.

* Community Health experienced preferred.

* Previous experience with medical residents preferred. Desire to work with medical trainees at all levels is essential.

Language Skills:

* Bilingual - English/Spanish fluency preferred.

SKILLS AND ABILITIES:

* Must meet all skills and abilities requirements in the BWH RN job description and additionally:

* Demonstrated knowledge of both hospital-based and community-based care and resources required

* Excellent communication skills, demonstrates patience, compassion and professionalism required

* Excellent analytical, judgmental, and interpersonal skills and demonstrated ability to work effectively with patients, families and co-workers

* Technical dexterity, in addition to Epic, must possess a demonstrated ability to work with a variety of information systems and databases, including but not limited to: Microsoft Outlook, Excel, Word, etc.

* Ability to be flexible and maintain equanimity in a fast paced, rapidly changing clinical setting - required.

* Must have the ability to function at the highest level professionally and clinically and further possess excellent interpersonal skills.