Nurse Home Visitor - Nurse-Family Partnership & Ccsi

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SUBSIDIARY: National Nurse-Led Care Consortium (NNCC)

PROGRAMS: 90% - Nurse-Family Partnership (NFP); 10% - Community Clinical Systems Integration (CCSI)

JOB OVERVIEW:

The Nurse-Family Partnership Public Health Nurse Home Visitor (NFP NHV) is responsible for providing comprehensive nursing services to first-time pregnant people and their families eligible for the NFP Program in Philadelphia. The NFP NHV maintains the highest standards in clinical practice and adheres to the national Nurse-Family Partnership model. NFP succeeds by having specially educated nurses regularly visit first-time parents, starting early in the pregnancy and continuing until the child’s second birthday. NFP NHVs are pivotal in supporting families to meet their life’s goals. Our goal is that all children are healthy, families thrive, communities prosper, and the cycle of poverty is broken. The NHV reports to the NFP Nurse Supervisor and works in collaboration with other Nurse Home Visitors, administrators, and senior staff to build and improve the strengths-based, client-centered culture.

The Philadelphia Nurse-Family Partnership is a program of the National Nurse-Led Care Consortium (NNCC), a nonprofit organization working to strengthen community health through quality, compassionate, and collaborative nurse-led care. NHVs split their time between NNCC’s West Philadelphia office (4601 Market Street) and fieldwork in the homes and communities of families served.

In this position, the NHV is also accountable to the Community Clinical Systems Integration (CCSI) initiative for 10% of their time.

RESPONSIBILITIES:

• Complete all required NFP and NNCC education, including but not limited to STAR Framework, Facilitating Attuned Interactions (FAN) training, Ages and Stages Developmental and Social Emotional Assessments, PIPE, Mental Health and IPV trainings, Cultural Consciousness training, DANCE, and regional and state education sessions.
• Provide regularly scheduled in-home visits and telehealth visits with clients.
• Build and maintain a caseload of 25-30 active clients within nine months of employment.
• Develop therapeutic relationships with clients utilizing concepts and processes from motivational interviewing, reflective listing, and FAN.
• Plan home visits in accordance with client goals and NFP outcomes and document all work appropriately.
• Support the achievement of client-identified goals through one-on-one education, active listening, screening, and referral processes to community resources.
• Support the policies, procedures, guidelines, and standards of NFP and NNCC.
• Adhere to ANA and PA nursing process and standards, code of ethics, HIPAA confidentiality standards, and the NFP model of home visitation.
• Contribute to and participate in clinical case conferences and professional development meetings including weekly team meetings, NFP All Teams meetings, organizational all-staff meetings, and regional, state, and national NFP education sessions.
• Meet weekly with the NFP supervisor for clinical reflective supervision and utilize the reflective process in supervisory sessions.
• Utilize nursing process to assess, plan, and document physical, emotional, social, and environmental needs of clients and their families as they relate to the NFP domains.
• Schedule joint home visits with NFP Supervisor every four months (3 times a year).
• Consult and collaborate with other professionals involved in providing services to clients and their families.
• Collaborate with outreach staff regarding community referral sources and disposition of referrals to NFP program.
• Contribute to a positive work environment that enables all staff to function at their highest potential.
• Provide timely documentation to data entry staff for input.
• Review documentation and data system reports entered in state, local, and national databases for accuracy, uniformity, and completeness.
• Commit to serving the greater good of communities and appreciate the public health implications.
• Recognize the role of race, income, age, immigration status, and other individualities in shaping health inequalities. Dependably advocate for more just policy results. Identify how own identity presents in the work and use feedback to continue learning about race, ability, and other individualities.
• Attend meetings with the Community Clinical System Integration (CCSI) workgroup to discuss efficiencies and reduce burden on both NHV and pediatric provider, enhance coordination of care for families, and continue to identify areas of alignment in care delivery.
• Implement strategies identified by the CCSI team with quality and participate in quality improvement efforts that aim to improve strategies for integrated care.
• Complete other responsibilities as needed.

REQUIRED SKILLS & QUALITIES:

• Detail-oriented; Able to focus on task at hand and to catch errors and fix them efficiently and professionally
• Strong time management skills and ability to be self-directed in accomplishing responsibilities
• Professional speaking and writing skills that are flexible and responsive to the audience served
• Strong documentation skills
• Moderate to advanced computer skills
• Able to work collaboratively with professionals, families, and community members
• Builds and maintains relationships with a diverse group of clients over a long-term period
• Works to understand and address their personal reactions to clients, welcomes feedback non-defensively, and makes good use of the reflective supervision provided
• Has a growth mindset about people vs. a fixed mindset about people. Believes that people can learn, change, grow, and improve.

HIGHLY DESIRED SKILLS & QUALITIES:

• Demonstrated commitment to valuing diversity and contributing to an inclusive working and learning environment
• Open and adaptive to change
• Interest in special projects as needed
• Bilingual (Spanish preferred)

JOB QUALIFICATIONS:

• Current Pennsylvania nursing licensure in good standing
• Work or student experience in public health, maternal-child health, mental health/behavioral health, or related field such as Early Childhood services in community settings
• Bachelor’s degree in nursing from an accredited university
• Current CPR/BLS certification

WORK REQUIREMENTS:

• Flexible schedule including some early evenings and weekends
• Work within the County/City of Philadelphia boundaries that include all city zip codes
• Physically able to perform job in home and community environments
• Light to moderate lifting and transport of program/client materials
• Use of personal automobile or public transit
• Work assignments involve travel throughout the designated area to multiple locations, including government and private agencies and partners.
• Prolonged computer-related exposure, as well as sitting and standing at workstations for long periods of time
• Local to regional travel or as required by National Service Office and funders

SALARY GRADE: 23

ADDENDUM:

If selected for the 2023-2025 Fiscal Years Community Clinical Systems Integration (CCSI) initiative, the overview and responsibilities, in addition to the NFP model responsibilities, are outlined below:

The CCSI project is a strategic partnership between the National Nurse-Led Care Consortium and the Public Health Management Corporation with the Children’s Hospital of Philadelphia (CHOP) PolicyLab and the CHOP Primary Care Network to design and implement an integrated system of care between evidence-based home visiting services and pediatric primary care with enhanced support for family engagement in quality childcare. Through a shared staffing model, the Nurse Home Visitors will work with CHOP pediatric primary care providers to promote greater positive healthcare outcomes with clients/patients/families over time that address social determinants of health. Nurse Home Visitors bring unique and valuable public health expertise that this partnership will use to augment primary care services in defined locations. Alignment and coordination of preventive services delivered in the home and office settings will increase efficiency and quality of care for children served by Nurse Home Visitors and pediatric primary care providers.

Public Health Nurse and Integration Specialist:

The work pattern is altered for this initiative. This is a full-time position funded .9 by Philadelphia NFP and .1 by CHOP/Vanguard with .90 FTE Nurse Home Visitor serving clients as determined by the evidence-based model and .10 within integrative care efforts. The .10 FTE will be used to support the continued implementation of the identified integration strategies with additional responsibilities to be determined in collaboration with NFP nursing supervisor(s), CHOP designated nurse manager(s), and project planning team to support the role of ambulatory care and the goals of NFP to meet pilot project determined deliverables. The following deliverables/responsibilities for this integration project are detailed below and are complimentary of the PHN Nurse Home Visitor responsibilities detailed above.

• Establish and retain a caseload consistent with model expectations for the designated FTE.
• Serve as a core member of the integration planning team which has the responsibility to design, implement, and evaluate the success of the piloted integration model.
• Serve as a member of clinical care team for the CHOP Care Network pilot site, including care team communication, referral coordination, and other clinical responsibilities to be determined by the integration planning team.
• Navigate and overcome unanticipated challenges and quickly adapt to new circumstances and changes as they arise within the scope of the CCSI effort.
• Exhibit proficiency in basic data requirements by program and state database. Receive training to be proficient in EPIC data entry.
• Contribute to the ongoing planning processes that frame a written document outlining alignment with evidence-based home visitation model and pediatric primary care providers and enrolled clients/families.
• Determine with others quality improvement initiatives that will be evaluated over time.
• Adhere to all CHOP educational requirements, including annual safety protocols and updates to patient electronic medical record system (EPIC).
• Document alignment and services including parent/child health and development screenings as determined by the integration team - such as Ages and Stages, using EPIC
• Collaboratively work with PolicyLab staff, primary care providers, nursing clinicians, and NFP/Mabel Morris colleagues, supervisors, and others as designated to develop positive, productive, and reciprocal communication strategies that support family health. Engage providers in clinical conferences that highlight the collaborative nature of program integration.
• Share lessons learned and program outcomes with colleagues, interested organizations, and providers at local-national conferences.
• Communicate with the PolicyLab CCSI project director when necessary.
• Maintain close communication with the Team Supervisor at all times.
• Function as a CHOP/NFP/MM liaison with individual teams as well as all staff as needed.
• Preferred: Commit to the term of the project with one-year renewals based on ongoing contributions to the project.

Other Requirements (must be on file):

• Current Commonwealth of Pennsylvania Child Abuse Clearance or pending
• Current Commonwealth of Pennsylvania Criminal Check Clearance or pending
• Current Federal Criminal Record Check through the FBI or pending
• Current Nursing Malpractice Insurance coverage
• Active NPI number
• Completed 2 step-TB test or pending
• Completed drug screening or pending
• Completed MMR, Varicella, Hepatitis B, and Tdap immunization records or pending
• Current flu and COVID-19 vaccination documentation

EOE