OBAT and Chronic Pain Registered Nurse

Position Summary

The RN is an integral part of the multidisciplinary care team responsible for ensuring that the primary care provider and practice team maintains a central role in the care process, by coordinating the care of these vulnerable patients, and ensuring the patients receive optimal care including acute illness management, chronic disease management, self-management coaching, and wellness/preventive care as they transition across multiple health settings and/or multiple physicians/providers.

Program Specific Essential Duties and Responsibilities

• Engages in daily team huddles by providing and soliciting input from other team members to enhance the team’s performance for patient care.

• Triages patients in person and by phone for patients who require immediate intervention including medication difficulties, urgent care appointments, and hospital admissions.

• Provides timely and frequent communications with the PCP and practice team to maximize the management of patient needs and related risk reduction.

• Ensures medication reconciliation is utilized according to standards.

• Documents the patient care discussion in the integrated care plan or plan of care.

• Works with team members to follow up on test results and referral results that are needed for decision making as appropriate for the integrated care planning process.

• Ensures that results are communicated with community services, health plans, facilities, and specialists.

• Follows the pre-approved protocols specific to population (e.g. Suboxone, Vivitrol).

• Supports self-management of patients’ health issues by using evidence-based approaches such as health coaching and motivational interviewing.

• Aids patients/families in self-management skills to identify problems, make decisions about the illness, preventative care, using resources, developing partnerships with primary care provider team, and taking action towards their goals.

• Aids patients/families or other support members with coaching or through referrals.

• Coaches patients/families towards goals by active participation in their plan of care, goal setting, identifying/removing barriers, problem solving, and identifying a plan for follow-through (e.g. visits, phone calls).

• Provides emotional support and documents evidence of patient’s involvement in their care.

• Identifies factors that are barriers to care for the underserved and vulnerable population (e.g. lack of housing, transportation, health literacy, language barriers).

• Coordinates care and tracks patients experiencing a transition to or from care facilities, and/or providers; assists in two-way communication between the PCP, specialists, and/or other specialty providers.

• Coordinates care with behavioral health services, specialty care, inpatient services, and non-clinical support in the community.

• Communicates in a timely manner (e.g., within 24-48 hours) with patients during transitions such as being discharged from an inpatient setting of the hospital.

• Follows up for patients who have Emergency Room visits when these patients are currently being followed by a Care Manager. This communication prevents readmission and related complications.

• Provides a smooth transition for same-day or urgent visits between patient and multidisciplinary team.

Qualifications and Education Requirements

• One of the following combinations of education and employment experience must be met in order to be considered for the position:

• Education and Experience: Associate Degree in nursing required. A nurse with a BS or Master’s Degree preferred. Minimum two years’ experience in case management, disease management, home health care nursing, or intensive outpatient education and/or self-management support. Experience with special populations preferred.

• Licensed RN by MA State Board of Registration.

• BLS required; ACLS preferred.

• Certified managed care nurse or registered nurse case manager preferred.