Population Health LPN

Monument Health Rapid City Hospital•Rapid City, SD

6d•Onsite

About The Position

At Monument Health, we’re committed to providing high-quality, patient-centered healthcare. We’re looking for a Licensed Practical Nurse (LPN) to join our population health team and help us achieve our goal of improving the health of the communities we serve. The LPN Population Health Nurse will work in collaboration with primary care providers and healthcare teams. The LPN provides nursing care to assigned patients under the supervision of the physician or Registered Nurse (RN) accepting delegation to meet the needs of the patient. The LPN provides nursing care in accordance with the policies and procedures of Monument Health, standards of the profession and in accordance with the South Dakota Nurse Practice Act, and other applicable federal, state and local regulatory and/or accreting agencies. The LPN will conduct basic health assessments, monitor health conditions, and collect patient data to assist in identifying health risks in the patient population and community. Monitor immunization status and assist with disease prevention programs, medication adherence, and promote healthy lifestyle choices. Participate in clinical pilots and programs, identify data trends and support performance improvement work. Monument Health offers competitive wages and benefits on qualifying positions.

Requirements

Completion of a nursing education program that is approved by a board of nursing
Licensed Practical Nurse (LPN) - South Dakota Board of Nursing

Nice To Haves

1+ years of Healthcare Experience

Responsibilities

Serve as a liaison between patients, families, and the interdisciplinary healthcare team to ensure that patient needs are met.
Conduct health risk assessments and screenings, provide promote education and referrals as needed.
Support population health initiatives aimed at improving the health of defined patient populations.
Monitor and evaluate the effectiveness of population health interventions.
Collect and analyze data to identify trends and areas for improvement in population health.
Advocate for policies and practices that improve population health.
Collaborate with community partners to support programs that address social determinants of health.
Provide assistance and support in the development of population health programs.
Works collaboratively with members of the care team to develop support a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the clinician.
Post reminders to ensure that all co-morbidities are discussed and documented during AWV.
Support competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists in the training of the care team to perform these screenings.
Support counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.
Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for clinician visit and CCM encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
In collaboration with the primary care physicians, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
Participate in huddles with primary care physician and care team; identify scheduling opportunities, special needs for patients, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling.
Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, AWV scheduling, transition of care follow-up calls/visits, and CCM encounters.
Collaborate with stakeholders to establish a method for assigning patients into a panel listing by clinician that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.
Other duties as assigned.