Nurse-AAoA

Nurse

Area Agency on Aging

Department of Human Services

Hourly Wage: $36.11-$40.64/Regular/Full-Time

Provides support for clients, which includes coordinating an array of services designed to improve the health of high needs, high-risk clients. Care coordination responsibilities will include assessment, care planning, monitoring of client status and implementation and coordination of services. Provides support to clients for effective care transitions, improved self-management skills and enhanced client-provider communication. Will facilitate interdisciplinary consultation, collaboration and care continuity across care settings. Offers clients, providers, and case managers with health-related assessment consultation in order to enhance the development and implementation of the client's plan of care for TXIX and Home & Community Case Management. Will perform case management duties and carry a caseload.

This position is not a direct care provider of intermittent or emergency nursing care, skills or services requiring physicians' orders and supervision.

Examples of Work Performed:

Coordinates follow-up activities and referrals with other programs including the Family Caregiver Support Program and HCS Medicaid Case Management.

Provides health-related assessment and consultation in development of the plan of care through the CARE Tool to case managers.

Completes Skin Care Protocol based on the ALTSA Long Term Care Manual.

Identifies and addresses barriers to overcome and impediments to accessing health care and social services.

Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient-centered, goal oriented Health Action Plan.

Assesses activation level for self-care through use of the Patient Activation Measure® (PAM®).

Provides evidence-based health assessments and screenings such as; BMI, PHQ-9, Katz ADL, PSC-17, GAD-7, AUDIT or DAST.

Provides transition support services that coaches the client to build confidence and competence in four conceptual areas, or \"pillars\": medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags of their condition and how to respond.

Works with supervisors and other health care providers, hospital discharge planners, skilled nursing facility staff, and staff at the client's health home to implement services and analyze the disposition of cases.

Performs facility visits, home visits, and follow up telephone calls to develop critical coaching relationships, to empower clients to take an active and informed role in their discharge planning.

Coordinates and communicates regarding the client's post-discharge status with all involved health care providers including, but not limited to: primary care, mental health, specialty care, and pharmacy.

Identifies and addresses barriers to overcome impediments to accessing health care and social services.

Provides referrals and advocacy for clients and their caregivers to community based services and supports which includes family caregiver programs, nutrition programs, in-home care and case management.

Provides teaching about self-management of the client's chronic health condition and provides resource links to ongoing chronic disease self-management support services.

Develops and maintains complete and concise client files in compliance with policy to appropriately document activities performed for the client and all elements required for specific programs.

Maintains all required documentation related to services provided and conforms to monthly deadlines.

Participates in staff meetings, public education and provider training sessions, as appropriate.

Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.

Prepares correspondence, memos, and client related written materials, as appropriate.

Participates in continuing education and training programs.

Works collaboratively with multi-disciplinary teams involving nurses, case managers and case aides.

Attends required meetings and trainings.

Knowledge, Skills and Abilities:

Knowledge of the long-term care system and services, issues related to aging and disability, and case management.

Knowledge of local in-home and community options and resources for the elderly and adults with disabilities and

their caregivers.

Knowledge of pharmaceuticals and their desired effects or complications.

Knowledge of direct functional assessment, service planning and implementation experience.

Computer and software skills including Word, Excel and database systems; ability to operate general office equipment; work at a desk using phone and computer for up to a full day's work schedule.

Ability to learn DSHS applications for case management and reporting.

Ability to communicate effectively both orally and in writing.

Ability to work independently in the field, with good judgment and a minimal supervision.

Ability to work effectively as a team member with a wide range of diverse staff and community members and to establish and maintain effective working relationships.

Ability to plan, organize, prioritize and coordinate work assignments and/or projects.

Ability to work under pressure, within short timelines to implement service plan.

Ability to defuse difficult situations recognizing the need for sensitivity as well as assertiveness.

Ability to produce written documents with clearly organized thoughts using proper English sentence construction, punctuation, and grammar.

Ability to maintain paper and electronic records and files of clients and services provided and to report those accordingly.

Ability to operate standard office equipment.

Demonstrated strength in learning and mastering new job responsibilities.

Ability to travel to and from client's homes and other community agencies that might not be ADA accessible.

Minimum Requirements:

Requires a Current Washington State Nurses License as a Registered Nurse with a BSN, or is in the process of obtaining an RN, BSN degree Washington State License within 3 months of employment.

Two years of nursing experience.

Maintain 45 CEU's every three years in accordance with the State of Washington.

Required to pass pre-employment background check.

Required to pass a pre-employment drug and alcohol test.

Must possess a valid Washington State Driver's License with the ability to obtain a Yakama Nation Driving Permit.

Enrolled Yakama Preference, but all qualified applicants are encouraged to apply.

Preferred Requirements:

Home health and psychiatric nursing background preferred.

Training in Coleman CTI or other coaching modality is preferred.

Experience working on cross-disciplinary, cross-organizational teams preferred.

Experience meeting and working with people in homes and other medical and community settings preferred.

Experience using motivational interviewing or other empowerment-based approaches preferred.

Salary : $36 - $41