Jan 06, 2020

Community Nurse - Population Health Dept

  • Cottage Health
  • Santa Barbara, CA, USA

Job Description

Provides basic medical care for patients experiencing homelessness as part of a new collaborative community program. Serves as the clinical liaison with Santa Barbara Cottage Hospital and community partners.
This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.
1. Clinical Practice Functions:
• Triage patients presenting to the Santa Barbara Connect Home program.
• Assess and intervene with patients per established hospital protocols.
• Assess and refer patients as appropriate.
• Performs initial assessments, patient education, coordination with primary care
provider, assisting patients with medications, and documenting and tracking patient medical needs and activities.
• Provide clear documentation related to patient care and condition, and maintains medical records.

2. Coordination and Collaboration Functions:
• Collaborate with Santa Barbara Connect Home partners to conduct street outreach, including rounds with City Net, SB City Police Department, SB City Fire Department, and/or other partners.
• Provide patient care management across the health care continuum including
preventive care relevant to patient.
• Collaborate with multidisciplinary teams when necessary.
• Facilitate follow up appointments
• Arrange appropriate referrals to outside facility dependent upon patient condition. Communicate clearly with accepting facility for ongoing care, as appropriate.
• Provide documentation for disability, insurance agencies, workers compensation, work releases and medical supply agencies.
• Assist with development and implementation of clinical practice guidelines.
• Work with Santa Barbara Connect Home outreach team to review analytics and patient satisfaction scores and adjust protocols when necessary.
• Communicates with consultants as needed and serves as a patient and family

3. Electronic Documentation:
• Update electronic documentation and provide clinical guidance on evaluation data collection.
• Create individual medical care plans for patients in the program.
Minimum: Associate's Degree in Nursing [RN]
Preferred: Bachelor's Degree in Nursing [BSN]
Minimum: Current, non-restricted California Registered Nurse license [for RN]. Valid class "C" California Driver License. Verification of acceptable driving record from the California Department of Motor Vehicles.

Minimum: Knowledge of advanced clinical standards, practices, and procedures for managing high-risk/at-risk patient populations; Knowledge of, and skill in, the use of personal computer and related software; Knowledge of the normal signs of aging, including growth and development, and ability to provide age appropriate care.
Preferred: Fluency in Spanish. Other advanced knowledge of computers including EHR software, Excel, PowerPoint and other degrees or certifications useful in health
related fields.
Minimum: A minimum of two years direct patient care experience in an acute care setting or managing high-risk patient populations in like programming is preferred.
Preferred: Previous work with patients experiencing homelessness or Psych nursing experience. Have an understanding that most illnesses and premature deaths are the result of lifestyle choices about diet, exercise, substance abuse, violence, and risk-taking behaviors.