Population Health RN

DEPARTMENT: Population Health

SUPERVISOR: Population Health Administrator; Clinical Supervision from Associate Medical Director of Quality Assurance, Population Health, and Community Health & Wellness (AMD of QA/PH/CHW)

STATUS: Exempt

SUMMARY:

The Prevention Nurse contributes to the implementation of preventive health activities at Esperanza Health Center (EHC). This individual will collaborate closely with the AMD for QA/PH/CHW and the Population Health Administrator to develop data-informed strategies to achieve preventive health goals across the health center. The Prevention Nurse provides clinical support and programmatic input into workflows for tertiary prevention for patients with chronic conditions, such as diabetes and hypertension, as well as those surrounding education, support, and clinical follow-up for patients who are prescribed PrEP (pre-exposure prophylaxis for HIV). In providing this clinical oversight, the Prevention Nurse will also have the opportunity to work closely with other population health and clinical support team members such as coordinators, navigators, care gap coordinators, screening assistants, and medical assistants, providing day to day clinical support.

The specific areas and disease conditions of focus for the Prevention Nurse's role may evolve over time to reflect current patient population needs and EHC priorities.

DUTIES AND RESPONSIBILITIES:

Preventative Services:

• Diabetes

• Provides clinical oversight to work and patient concerns regarding diabetes for Diabetes Care Coordinator and Diabetes Care Navigators.

• Collaborates closely with other Population Health Staff such as AMD for QA/PH/CHW, Diabetes Care Coordinator, Diabetes Care Navigators, and Care Gap specialists to provide comprehensive support to patients with diabetes.

• Educates staff as needed on relevant clinical topics, such as medications, self monitoring of blood glucose, etc.

• May assist as needed with clinical efforts among patients with diabetes, including but not limited to the following:

• Collaborates with PCP to assist with diabetes education, insulin titration, diabetic foot care, and other care needs.

• In collaboration with Diabetes Care Coordinator,, assists with ordering supplies, including submitting prior authorizations as needed.

• Hypertension

• Assist with the development of hypertension patient education curriculum.

• Assist with training clinical staff (including Medical Assistants) on hypertension workflows, on topics including but not limited to:

• Lifestyle modifications

• Blood pressure measurement technique

• Medication adherence

• May assist as needed in patient care visits or by follow-up phone calls to provide additional patient education, clinical assessment of blood pressure readings, etc.

• PrEP

• Collaborates with the Population Health Administrator and Care Gap Specialists for HIV prevention within the health center.

• Reviews spreadsheet of patients receiving PrEP on a monthly basis at minimum to ensure timely follow-up on care related to PrEP such as labs, PCP appointments etc. Provides clinical input to follow-up needed to Population Health Administrator and Care Gap Specialists and/or PCP as necessary.

• Maintains and documents workflows surrounding PrEP lab protocols, prescriptions, etc.

• Assist in providing PrEP updates and continual training for clinicians and other clinical staff with an assigned Associate Medical Director championing PrEP workflows.

• Participates on EHC's behalf at meetings with partner organizations, as directed by the Population Health Administrator, to gather PrEP clinical updates and contribute to citywide efforts to decrease HIV transmission.

• Other: Assists with other population health and quality assurance needs as directed by the Population Health Administrator.

Other:

• Ability to integrate faith and clinical practice.
• No on-call responsibilities; no weekend hour required
• Other duties and responsibilities as assigned.

General Patient Services:

• Work with the primary care practitioners to develop care plans for disease management; coordinate care and complete tasks as necessary to complete care plan goals.
• Coordinate patient care with primary care practitioners and communicate with primary care practitioners regarding patient progress.
• Collaborate with Esperanza health care team members (i.e. dietitian, social services).
• Inform outreach workers of patient intervention and disease-specific targets.
• Assist with self-management goal setting and monitoring.
• Conduct patient phone calls, as necessary.
• Educate patients and families regarding disease management and general health

maintenance.

• Track preventive health maintenance items for patients.
• Occasionally see patient alongside primary care practitioner when indicated,

performing history tacking, medication reconciliation, etc.

• Monitor collected data and patient progress, in collaboration with an assigned Associate Medical Director
• Play a consistent and active role in identifying project inefficiencies and finding effective, collaborative solutions to problems, with the goal of improving the quality of care.

GENERAL EXPECTATIONS:

• Self-directed and motivated.
• Strong written oral/written communication is required.
• Exceptional organizational and interpersonal skills, with attention to detail required.
• Exhibits self-motivation in undertaking new projects and assignments.
• Independently identifies and resolves problems.
• Pursues personal and professional development.
• Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings
• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment
• Ability to analyze systems and to develop creative solutions to problems.
• Demonstrated ability to work well with people of various ages, backgrounds,

ethnicities, and life experiences.

• Adheres to policies and procedures of the health center and the regulations of governing agencies as they affect the department, recommending changes where appropriate.
• Demonstrates habit of good attendance and punctuality by reporting for work whenever scheduled.
• Participates in departmental meetings and general staff meetings.
• Requires the ability to travel to multiple office locations
• Provides effective spiritual intervention with patients, sharing hope and salvation through Jesus Christ, sharing helpful Biblical instruction and scriptures, praying for patients, and

connecting/referring to Christian churches as appropriate and according to the leading of the Holy Spirit. Does not force spiritual intervention, but gives spiritually uninterested

patients respect and space, continuing to provide exemplary care in all other dimensions.

• Serves all patients in a Christ-like manner, with respect, humility, love, and self-control.

EDUCATION, KNOWLEDGE, SKILLS, AND QUALIFICATIONS:

• Registered Nurse license required; BSN preferred
• Good oral and written communication skills - Bilingual English/Spanish preferred
• At least 1-2 years of experience providing clinical services required
• Maintains CPR certification.
• Solid interpersonal skills, including ability to deal with people politely, even when they are impolite. Must communicate warmth and be able to put people at ease.
• Ability to remain calm under pressure.
• Ability to take initiative in communication, being clear and direct, in order to effectively communicate with other staff.
• Some computer experience - word processing and/or other. Competency in Google Suite, knowledge of database and data analysis preferred.
• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.
• Ability to analyze systems and to develop creative solutions to problems.
• Must show ability to organize, process, and verify details.
• Must have a solid record of handling confidential information, as well as demonstrating trustworthiness and honesty in all transactions.
• Solid character references, as well as no criminal record. Also, a solid record of timeliness and reliability in a work setting.
• Experience in community/outpatient setting and case management preferred.
• Experience serving in poor, urban environments, familiarity with North Philadelphia is preferred.

WORKING CONDITIONS:

• Requires the ability to travel to multiple office locations within North Philadelphia
• Requires the ability to be on your feet working in a high paced environment for 4 hours at a time.
• Requires the ability to work in a seated position on the phone for 4 hours at a time.
• Requires extensive work on a computer keyboard.
• Requires the ability to work with adults and children.
• Requires work with needles and patient's bodily fluids.