Registered Nurse - LATS

About the role

The Registered Nurse – Recuperative Care (RN-RC) provides admission screening and intake, care planning, case management, patient education and health navigation, and clinical care within the scope of practice, for patients being discharged from the hospital setting without stable housing for recovery.

Responsibilities

• Screen referrals from hospitals and coordinate with discharge planners to assess patient acuity, program requirements, and bed availability to determine appropriateness for RCP admission.
• Identify potential clinical and supportive service needs while within respite program.
• Proactively communicate with RCP participant’s primary care team (VG or external) to facilitate early post-hospital contact.
• Obtain required consents and releases for coordination of care.
• Develop care plan based on patient goals and the reason for admission to RCP.
• Gather information for a clinical care plan including physical and psychological history and assessment; list of current medications, dosages, and allergies; vital signs; other pertinent information, such as laboratory or other test results.
• Identify discharge indicators and develop a discharge plan with patient.
• Participate in and facilitate multi-disciplinary care coordination meetings with appropriate providers (e.g., PCP, home health, pharmacies, specialty care).
• Care for patients in a homeless shelter setting, providing basic medical supervision and care coordination.
• Coordinate with shelter case management to address SDOH and other non-clinical needs.
• Provide shelter staff education and support around basic medical knowledge as relevant for evening and weekend supervision of RCP residents.
• Huddle daily with RCP team to create and implement daily action plans, performing transition of care visits for patients being discharged from hospitals, following up with outside provider recommendations after outpatient visits and ensuring that treatment recommendations and medication changes are acknowledged and actualized.
• Facilitate patient access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies (as needed).
• Provide patient education and health coaching on topics including diabetes, hypertension, and other chronic diseases, including assisting patients with self-management goal setting.
• Educate patients on how to utilize after-hours number or daytime nurse triage to address immediate clinical needs and provide guidelines for when to contact RCP team or PCP vs. seeking emergency department care.
• Log vital signs and monitor for changes in health status as indicated by the care plan.
• Administer pre- and post-procedural or operative care, including minor wound care per discharge instructions, monitor for changes in health, and recommend follow-up services as needed.
• Support self-administration of medications and patient progress towards self-management of medications.
• Coordinate with clinical pharmacy where appropriate.
• Assist with prescription management and reconciliation in conjunction with clinical pharmacy where appropriate.
• Advocate for medication regimen simplification, as needed.
• Identify and implement strategies to support independence in health management.
• Document all clinical care provided during RCP stay.
• Administer medication or vaccines under protocol and administer oral, I.M. and I.V. medication as ordered by a provider.
• Perform laboratory procedures when necessary.
• Develop and follow standardized protocols and interventions appropriate to RCP based on common diagnoses in conjunction with medical director.
• Prepare patients for discharge from the RCP to their new housing locations.
• Remain available by cell phone during RCP visits.

Requirements

• Current Oregon RN License required.
• Previous experience working with people experiencing homelessness desirable.
• Prior experience with Epic preferred.

Qualifications

• Proficiency in English and Spanish, both written and spoken language preferred.
• Desire to work with complex patients including people who are houseless and who may be struggling with mental health and/or substance use.
• High level of skill in interpersonal relations and problem solving.
• High energy and self-directed individual with excellent interpersonal, problem solving, organizational and computer skills.
• Ability to take initiative to proactively organize and manage the responsibilities of the job.
• High degree of integrity and professionalism.
• Ability to work in challenging environments in the community.
• Ability to work as an integral part of a high functioning team.
• Excellent Customer Service skills.
• Commitment and alignment to Virginia Garcia’s mission, vision and values.
• Valid driver’s license, reliable transportation, safe driving record and insurance coverage required.

Skills

• Knowledge of healthcare policies and procedures.
• Ability to handle sensitive and confidential information.
• Strong communication and collaboration skills.
• Ability to work independently and as part of a team.
• Basic knowledge of medical terminology and procedures.
• Ability to prioritize and manage multiple tasks simultaneously.

Benefits

Virginia Garcia Memorial Health Center offers competitive compensation and benefits, including:

• Health insurance coverage.
• Paid time off and holidays.

• Pay

  Salary range for this position is $45,000 - $55,000 annually, depending on experience and qualifications.

  Schedule

  This position requires a flexible schedule, including evenings and weekends, to accommodate the needs of the RCP program participants.