Nurse Outreach Program Manager

SUMMARY: The Nurse Outreach Program Manager will provide direct nursing care and oversight of nursing outreach functions in the community, as well as coordinate a team of nurses and harm reduction staff in the development and implementation of mobile healthcare services at a Federally Qualified Health Center. NACC’s nursing Outreach Program will provide preventive health and acute care services within a mobile unit, as well as within Southside Harm Reduction Services’ drop-in center, and in other outreach settings, focusing on serving people experiencing barriers to healthcare including homelessness and substance use.

DUTIES AND RESPONSIBILITIES:

• Professional Nursing Care and Outreach-Based Care Coordination
  1. Provide professional nursing care (including triage, assessment, intervention, evaluation) in varying community settings, prioritizing trauma-informed care principles and patient-led care plans.

1. Deliver skilled interventions including, but not limited to, wound care and assessment, foot care, medication and vaccine administration, phlebotomy, education, standing orders, and vital signs.
2. Conduct nurse-led visits through the utilization of standing orders.
3. Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.
4. Provide health services stationed part-time at Southside Harm Reduction Services’ harm reduction drop-in center. Work closely with Southside’s staff to coordinate care for Southside clients and serve as a health-services resource to staff and volunteers of the drop-in space.
5. Utilize harm reduction strategies to address health concerns disproportionately affecting unhoused populations including HIV, hepatitis C, STIs, wounds, foot health, asthma, diabetes, substance use disorder, overdose risk, and behavioral health concerns. Provide harm reduction services including naloxone, syringe and safer use supplies and education.
6. Perform assessments of patient’s unmet medical, behavioral, and social care needs and support the care team in meeting these needs. Help patients navigate community resources and specialty care, as well as linkages to primary care when needed. Work to reduce barriers through follow-up, transportation support, appointment reminders, and other strategies. Provide advocacy on behalf of patients seeking outside care.
7. Work collaboratively with clinic staff to identify high-risk or out-of-care individuals. Offer mobile care coordination services and linkages to care as appropriate.
8. Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol.
9. Read and interpret patient charts and lab results. Review new labs and identify need for provider follow up. Communicate with provider as needed.
10. Assist patients in care transitions, such as entering or discharging from treatment, hospitalizations, respite programs, and shelters. Work with external service providers to ensure continuity of care.
11. Facilitate rapid access to HIV and hepatitis C care, PrEP, PEP, and buprenorphine for substance use disorder.
12. Support care plan and medication adherence through medication set up, delivery, and routine lab draws.

• Program Management
  1. In collaboration with Medical Leadership, lead a small group of staff in a transition from in-clinic to outreach-based health services.
  2. In collaboration with Medical Leadership, develop policies and procedures to support mobile health services utilizing evidence-based practices and patient-centered care models.
  3. In partnership with medical Leadership and Southside Harm Reduction Services, develop and implement health services for people who use drugs delivered out of a new community drop-in space.
  4. Work in partnership with Medical Leadership and Quality Team to monitor QA, QI, and performance reports. Coach and mentor staff to address continuous quality improvement in clinical care, customer service, and outreach.
  5. Supervise and lead the day-to-day work of clinical outreach staff.
  6. Develop relationships with community organizations and individuals to ensure collaboration and partnership to advance program goals.
  7. Communicate frequently and directly with team members on patient needs and direction of daily work and larger issues affecting the health status of homeless individuals.
  8. Utilize staff teams within NACC to refer clients appropriately, including but not limited to the patient advocate, population health, MAT services, infectious disease treatment, and other teams.
  9. Initiate and lead targeted ‘in-reach’ and outreach to engage, educate, refer, and connect out-of-care patients to integrated health care services.
  10. Oversee the management of medication stock and clinic supplies; maintain an inventory system, including par levels for all medications and supplies; complete monthly medication inventory to ensure compliance with 340b audits; inventory expired medications and dispose appropriately. Document data, plans, clinical actions, client progress, response to care and other relevant patient information in EHR.

SUPERVISORY RESPONSIBILITIES:

• Directly supervises employees within the Outreach Nursing Program.
• Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
• Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

QUALIFICATIONS:

• Bachelor’s or master’s degree in nursing.
• Public health nurse registration preferred.
  • Clinical experience in community health and outreach-based nursing.
  • Proven experience in program development, management, and evaluation.

• Experience working with chemically dependent adults and knowledge of harm reduction principles.

• Basic competence in duties and tasks of supervising employees.
• Excellent verbal and written communication skills.
• Commitment to excellence and high standards.

• Strong organizational, problem-solving, and analytical skills; able to manage priorities and workflow.
• Ability to work independently and as a member of various teams and committees.

• Acute attention to detail.
• Ability to deal effectively with a diversity of individuals at all organizational levels.
• Good judgement with the ability to make timely and sound decisions.
• Demonstrated ability to plan and organize projects.

• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.