Diabetic Team Nurse Educator

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Beth Israel Lahey Health Primary Care (BILHPC) is building a high performance primary care model that will enable the organization to be a leader in patient experience, provider and care team work life and quality of care both regionally and nationally. Additionally we are working to establish a diabetes education program which will provide quality care and medication-assisted therapy for patients with diabetes in an outpatient setting.

The responsibilities for the Diabetes Educator Team Nurse include partnering with providers, pharmacists, nutritionists and other members of the care team to help educate, support and improve health outcomes of patients with diabetes. The Diabetes Educator Team Nurse will serve a resource for the Region in educating and supporting people affected by diabetes to understand and manage the condition, achieve behavioral and treatment goals, and optimize health outcomes. The Diabetes Educator Team Nurse will participate in Diabetic Group sessions, provide educational sessions and tools for care teams and Team Nurses, maintain a working relationship with Joslin Care Network, and partner with BILH Primary Care Leadership 1-2 hours per month creating and presenting educational materials.

Job Description:

Primary Responsibilities:

1)    The Diabetes Educator Team Nurse  will perform all of the duties of a Team Nurse, including:
    a.    Coordinate and facilitate quality clinical management of a broad based outpatient population across the continuum of care. Collaborates with providers to identify needs for preventive care, evidence-based chronic disease management and care coordination. Provides general and specific healthcare education.  Works directly with patients to identify and monitor self-management goals. (essential)
    b.    Collaborates care with community based providers. Follows up on ED visits and inpatient discharges. Assists providers with exams, treatments and procedures as needed. (essential)
    c.    Provides skilled telephonic triage and assessment, education, collaboration and coordination of healthcare and community resources. Performs a direct patient care role.  Nursing visits include : Annual Wellness Visits (AWVs) and Chronic Care Management (CCM) of our BIDHC patients. (essential)
    d.    Responsible for INR management and teaching for those patients on Coumadin using a standardized protocol. (essential)
    e.    Administers vaccines and medications by parenteral, oral, rectal or nasal route by orders of the prescribing provider and by the Medication Administration policy guidelines established by BIDHC . Provides patient education as appropriate for the administered medication. (essential)
    f.    Performs a wide range of nursing activities as needed under the direction of the provider such as wound care, point of care testing etc. Accurately documents all aspects of patient care in the Electronic Health Record in a timely basis. Schedules tests and referrals for specialty care on order of provider. (essential)
    g.    Monitors and ensures follow up of all abnormal test and imaging results under the direction of the provider. (essential)
    h.    Oversees the inventory and ordering management of clinical supplies and equipment as necessary. Ensures safe, accurate and clinically appropriate collection, storage and processing of all biologic specimens. (essential)
    i.    Provides oversight, delegation and acts as a resource to unlicensed staff including MAs, Certified Nursing Assistants and Nursing Students. Provides on-going education and training to practice staff. Updates clinical knowledge and skills though consultation, review of literature and formal and informal education including CEUs. Maintains compliance with organizational mandatory annual training. (essential)
    j.    The Team Nurse will ensure that PHI (Patient Health Information) will only be used for the purposes of patient TPO (treatment, payment and operations).   The Team Nurse will ensure patient safety practices to prevent/eliminate risk of patient harm. Adverse patient events and near misses will be promptly reported to the BIDHC Risk Management Dept. (essential)

2)    The Diabetes Educator Team Nurse will perform the following duties related specifically to diabetes education:
    a.    Perform clinical and psychosocial assessment of diabetes patients in either an individual or group setting.
    b.    Identify educational needs for diabetes self-management knowledge and skills.
    c.    Develop and implement a plan of care based on clinical expertise, scientific principles and the patients' lifestyle and culture.
    d.    Empower diabetes patients with knowledge and skills to attain optimal control and pr