Implements nursing outreach activities for the elderly and the disabled in both residential and community settings. Works collaboratively to organize care coordination and outreach to these high-risk residents. Job Responsibility Consults with the appropriate parties to coordinate the discharge process; recommends a comprehensive home-based plan-of-care based on an in-depth assessment of the patients needs. Responds to referrals; provides educational services, safety assessments, pre-surgical te... more details
Job Description
Implements nursing outreach activities for the elderly and the disabled in both residential and community settings. Works collaboratively to organize care coordination and outreach to these high-risk residents.
Job Responsibility
Consults with the appropriate parties to coordinate the discharge process; recommends a comprehensive home-based plan-of-care based on an in-depth assessment of the patients needs.
Responds to referrals; provides educational services, safety assessments, pre-surgical teaching and information to manage existing disease and/or chronic conditions; assists in the establishment of policies/procedures to ensure the safety of vulnerable, at-risk residents.
Defines, assesses, and understands the health status of populations, determinants of health and illness, factors contributing to health promotion/disease prevention, and factors influencing use of health services.
Utilizes knowledge of health status measurement tools, bio-statistics and risk assessment methodology to create high-risk criteria; develops and implements processes for identifying patients at high-risk for loss of further independence.
Trains co-workers to identify high-risk residents; engages high-risk residents through outreach and utilizes knowledge regarding third-party reimbursement and community resources to ensure proper treatments are rendered.
Utilizes methodologies encompassing comprehensive geriatric assessment to identify newly emerging health conditions requiring additional medical or psychosocial interventions; utilizes sound interviewing and assessment techniques to evaluate residents, and interprets and disseminates the results to concerned parties.
Utilizes systematic method of follow-up to ensure interventions are conducted; utilizes knowledge regarding third-party reimbursement and community resources and conveys appropriate information as necessary.
Plans program responses based upon results of regularly scheduled health screenings (hypertension, diabetes, cancer, cholesterol, etc.) community health assessments, health status analysis; designs outreach efforts that increase the percentage of community residents who are immunized against influenza and pneumonia.
Conducts and analyzes results of screenings and questionnaires to design and assist in the implementation of health promotion activities that meet the needs of the majority of the residents; documents results of the evaluation, assessment and plan in the appropriate record; facilitates group education sessions on common problems.
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Job Qualification
Graduate from an accredited School of Nursing required. Bachelors Degree in Nursing, preferred. Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
*Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).
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