Senior Community Health Nurse (42638)

Under the general supervision of the Director of Quality Management, the Sr. Community Health Nurse provides comprehensive home visit nursing services using a referral based process. The incumbent works in collaboration with the care coordination and case management multi-disciplinary team in addressing the needs of referred patients and families. Works with community partners to address social determinants of health factors that are impacting the health needs of referred patients and families. The work includes assessment and nursing diagnosis as well as counseling and prevention services. Functions autonomously and routinely interacts with other area resources and at times will need to facilitate response in order to access services for patient(s). Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Integrates ethical provisions and leadership in all areas of public/community health nursing practice.
• Advocates protecting the health, safety, and rights of the individual, family, community, and population.
• Acts independently and within the professional nursing standards and the nursing standards and the nursing scope of practice, and established “Physician Standing Orders,” to engage, identify, and address the health needs of the referred individuals and families across the age spectrum for home visit nursing care services.
• Implements a patient centered-home visit nursing care services within the standards of care and the nursing scope of practice.
• Implements critical-thinking strategies in the field and evaluates the severity of health care related matters encountered in the communities.
• Directs patient care based on assessment skills when determining trip to the local field clinics or when to require implementation of Emergency Medical Services (EMS) system.
• Coordinates and participates in the planning, implementing, and addressing psychosocial issues and concerns in patient care.
• Collaborates with the Care Coordination and Case Management team  in the planning, implementation, and evaluation of a comprehensive plan of care using evidence based nursing practices to meet the health care needs of clients.
• Provides education, coordinates, and case manages referred patients living with chronic disease illnesses via home visit program.
• Provides home care self-management education to clients.
• Assists with maintaining the Standards of Care guidance for the various chronic disease illnesses and home visit policies and procedures. 
• Provides/Facilitates/Coordinates Self-Management Education classes in the communities.
• Identifies and prioritizes care to clients with high-risk conditions.
• Documents patient encounters via Electronic Health Record using the community health nursing template that incorporates patient self-assessment and goal setting information.   
• Provides primary, secondary, and tertiary prevention activities in the community i.e. health fairs.
• Considers factors