OBAT and Chronic Pain Registered Nurse

Family Health Center•Worcester, MA

10d•$31 - $38•Onsite

About The Position

The RN is an integral part of the multidisciplinary care team responsible for ensuring that the primary care provider and practice team maintains a central role in the care process, by coordinating the care of these vulnerable patients, and ensuring the patients receive optimal care including acute illness management, chronic disease management, self-management coaching, and wellness/preventive care as they transition across multiple health settings and/or multiple physicians/providers.

Requirements

Associate Degree in nursing required.
Licensed RN by MA State Board of Registration.
BLS required.
Minimum two years’ experience in case management, disease management, home health care nursing, or intensive outpatient education and/or self-management support.

Nice To Haves

A nurse with a BS or Master’s Degree preferred.
Experience with Special Populations preferred.
ACLS preferred.
Certified managed care nurse or registered nurse case manager preferred.

Responsibilities

With the Team Leader, engages in daily team huddles by providing and soliciting input from other team members to enhance the team’s performance for patient care. Huddles include information and follow up tasks for patient care.
Triages patients in person and by phone for patients who require immediate intervention including medication difficulties, urgent care appointments and hospital admissions.
Provides timely and frequent communications with the PCP and practice team to maximize the management of patient needs and related risk reduction.
Ensures medication reconciliation is utilized according to standards.
Documents the patient care discussion in the integrated care plan or plan of care.
Works with team members to follow up on test results and referral results that are needed for decision making as appropriate for the integrated care planning process. Ensures that results are communicated with community services, health plans, facilities, and specialists.
Follows the pre-approved protocols specific to population (e.g. Suboxone, Vivitrol).
Supports self-management of patients’ health issue by using evidence based approaches such as health coaching and motivational interviewing.
Assists patient/family in self-management skills to identify problems, make decisions about the illness, preventative care, using resources, developing partnership with primary care provider team, and taking action towards their goals.
Assists the patient/family or other support member with coaching or through a referral.
Coaches patients/families towards goals by active participation in their plan of care, goal setting, identifying/removing barriers, problem solving, and identifying a plan for follow through (e.g. visits, phone calls).
Provides emotional support and documents evidence of patient’s involvement in their care.
Identifies factors that are barriers to care for the underserved and vulnerable population (e.g. lack of housing, transportation, health literacy, language barriers).
Addresses the health needs and management of a specific population (e.g. patients with opioid dependence).
Coordinates care and track patients experiencing a transition to or from care facilities, and/or providers; assists in two-way communication between the PCP, specialists, and/or other specialty providers.
Coordinates care with behavioral health services, specialty care, inpatient services, and non-clinical support in the community.
Communicates in a timely manner (e.g. within 24-48 hours) with patients during transitions such as being discharged from an inpatient setting of the hospital. Follow-up for patients who have Emergency Room visits when these patients are currently being followed by a Care Manager. This communication is to prevent readmission and related complications.
Provides a smooth transition for same day or urgent visits between patient and multidisciplinary team.