Sash Wellness Nurse

I. Position Summary:

The SASH Wellness Nurse is responsible for providing and/or overseeing wellness care and health coaching for SASH participants in accordance with the SASH Wellness Nurse Core Competencies, and for overseeing the well-being of participants and coordinating health services with other members of the SASH Team and other community health providers. The nurse supports a philosophy of aging in place and a participant-centered approach to care consistent with the mission of SASH.

II. Principal Responsibilities by Intervention Category

A. Foundations of Wellness Nursing: The Wellness Nurse must possess the core knowledge and preventive health-care philosophy fundamental to the SASH wellness nursing practice in the domains of:

· Wellness promotion;

· Illness prevention and health preservation; and

· Community-based nursing practices.

B. Elements of SASH Wellness Nursing: The Wellness Nurse must possess competencies that focus on nursing activities, interventions, goals and outcomes that are central to the SASH wellness nursing practice:

· Care Coordination: The Wellness Nurse plays a central role in ensuring coordinated care and services are provided for SASH participants by performing the following duties related to the coordinated-care interventions of SASH:

o Conducts wellness assessments with SASH participants;

o Helps SASH team identify high-, moderate- and low-risk participants;

o Participates in regular SASH team meetings, ensuring close interaction and coordination among care providers without duplicating services;

o Provides input to SASH Coordinator on the development of individual Healthy Living Plans (HLPs) with particular attention to moderate- and high-risk participants;

o As determined in SASH team meetings, takes the lead in implementing targeted interventions when appropriate to help participants meet their self-identified wellness goals;

o In collaboration with the SASH Coordinator, monitors participants’ progress in reaching their HLP goals and documents any changes to individual HLPs agreed to by the participant; and

o On an as-needed basis, delegates tasks to the SASH Coordinator and/or personal-care attendant in accordance with the Nurse Delegation Procedure in order to ensure that adequate supports are in place for participants;

C. Transitional Care: The Wellness Nurse performs the following duties related to the transitional-care interventions of SASH:

o Communicates with SASH team members to facilitate safe and effective transitions for SASH participants between off-site care facilities and home;

o Implements home-visit interventions as necessary; provides in-person home visits with SASH participants after a return home; and, as appropriate, follows home-visit intervention strategies of the evidence-based Care Transitions Intervention (Coleman et. al.), including planning for self-management of medications, coaching on the importance of scheduling follow-up medical appointments, and educating the participant on how to identify early warning signs of health complications;

o Updates the “Encounter Notes” section of the participant’s Health & Wellness Record so that all SASH team members have current information; and

o Communicates to SASH Coordinator(s) the need for wellness checks and any additional care-coordination tasks, and delegates any other required duties to the SASH Coordinator or personal-care attendant as appropriate in accordance with the Nurse Delegation Procedure.

D. Self-Management Education: In concert with the SASH Coordinator, the Wellness Nurse plays an important role in coaching, encouraging and promoting participants about the importance of self-management of chronic health conditions. The Wellness Nurse provides regular wellness visits and programming (both one on one and in group settings) and performs the following duties related to the self-management education interventions of SASH:

o Preventive wellness care interventions, including blood-pressure clinics, evidence-based educational programs, medication reviews, overall health status reviews, and sharing of information and resources.

o Medication reviews with each participant, updating the person’s medication record as necessary, communicating any discrepancies or concerns regarding the medication regiment with the participant and with the PCP office if deemed necessary, and collaborating with the participant on a plan for medication self-management;

o Monitoring each participant’s overall physical and mental status, documenting status changes or concerns in the participant’s SASH record, and reporting any changes to the SASH team, family members and PCP as appropriate; and

o Educating participants about their health issues, stressing the importance of participating in activities and evidence-based practices that promote good health, alleviate symptoms and help manage chronic conditions; and

o Instilling in participants the importance of regular and open communication with their primary care provider(s).

· Therapeutic Partnership: The Wellness Nurse continuously adapts practices to meet the holistic needs of the SASH participant, taking into account individual socioeconomic, cultural, ethnic and spiritual values and beliefs in order to develop rapport.

III. Other General Responsibilities

· Works independently and as part of a team to carry out job duties.

· Demonstrates basic computer competence and the ability to learn all relevant applications (i.e., electronic health records, care-management systems, spreadsheets, email and office software).

· Understands the critical importance of consistent and accurate data collection in order to inform SASH clinical outcomes.

· Communicates in a positive and respectful manner with participants, co-workers, visitors and family members.

IV. Professional Standards of SASH Wellness Nursing

· Demonstrates a commitment to the mission and values of SASH and the employing agency.

· Demonstrates respectful and effective communication with co-workers, participants, families and vendors.

· Protects the privacy and confidentiality of information related to participants, families, staff and general organizational operations.

· Follows HIPPA guidelines regarding client confidentiality.

· Conducts self in a safe manner by adhering to all work safety practices, rules and standards.

· Demonstrates a commitment to quality and proactively seeks to make improvements to systems and processes.

· Maintains a professional appearance that is appropriate for the position.

· Reports to work on time, provides advance notice for time off, completes timesheets accurately and appropriately manages combined time off.

· Demonstrates integrity in work habits and the use of SASH resources.

· Willing to occasionally fill in for other Wellness Nurses and perform duties as assigned that may be outside principal responsibilities.

IV. Minimum Qualifications

· Must be currently licensed as a Registered Nurse in Rhode Island, with demonstrated leadership skills and the ability to exercise sound judgment. At least two years’ experience in a clinical setting strongly preferred. Must be Bilingual, (English/Spanish). Must know standard record-keeping procedures and legal requirements (e.g., progress notes, HIPPA guidelines). Must be able to work independently and as part of a team. Must possess strong organizational and time-management skills and have excellent verbal and written communication skills.

VI. Working Conditions & Physical Demands

· Must be able to lift/push up to 25 pounds.

· Must be accepting of health conditions and behavior of participants; some may have difficult behavioral challenges and/or demanding family members and/or guardians.

· Must be adaptable to working in an ever-changing, high-pressure work environment.

· Must be in good general health and demonstrate emotional stability.

· Must have driver’s license and vehicle and be willing and able to work at various locations.

Job Type: Part-time

Pay: $35.00 per hour

Expected hours: 20 per week

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Ability to Relocate:

• Pawtucket, RI 02860: Relocate before starting work (Required)

Work Location: In person