Street Medicine RN Case Manager

San Francisco Community Health Center•San Francisco, CA

3d•Hybrid

About The Position

The Street Medicine RN Case Manager will help plan, coordinate, and oversee nursing services for a patient panel on the SFCHC Street Medicine team. The RN will work in collaboration with providers and other members of the Street Medicine team and Wellness Clinic team to provide direct patient care and manage the longitudinal clinical care of the Street Medicine patients through the design and implementation of complex care plans that address patient-centered goals. The RN Case Manager will be an integral member of the Enhanced Care Management (ECM) team within clinic services, including serving as a Lead Care Manager for a subset of the Street Medicine patient panel. Enhanced Care Management is a Medi-Cal program seeking to provide intensive care coordination for patients experiencing complex medical and social comorbidities. In addition to clinical support, the RN will help us achieve program administrative goals, such as documenting and tracking patient outcomes. Medical care will happen in both clinical and community settings, including drop-in clinics, on sidewalks, in tents and encampments, or in patient homes. The RN must be comfortable working in non-traditional care settings and providing care to people who use substances, with complex mental health and medical diagnoses. In addition, the RN will work collaboratively with community partners and area hospitals to coordinate care across the continuum and accept referrals for patients who would benefit from connection to mobile, community based primary care. Opportunities will be available for professional growth and development through participation in educational programs, review of current literature, in-service meetings, workshops, and conferences.

Requirements

Bachelor's degree in Nursing; at least 3 years of experience that can be demonstrated to be applicable to the duties listed in the job description. OR Associate's degree in Nursing; at least 5 years of experience that can be demonstrated to be applicable to the duties listed in the job description.
State of California Licensed Registered Nurse or licensure pending as documented by temporary licensure.
Current BLS certification.
Effective written and verbal communication skills.
Must have a philosophy that is consistent with the Mission, Vision, and Core Values of the organization.
Ability to organize, plan, and effectively work on an interdisciplinary team.
Must be able to travel on foot around the Tenderloin neighborhood and surrounding area.
Must be able to carry medical supplies in a backpack to patients within the community.
Up to date with vaccinations, especially seasonal flu shot vaccine and most recent COVID-19 vaccination.
Must obtain TB clearance and complete background check upon hire.

Nice To Haves

Experience working with people of diverse backgrounds (gender identity, sexual orientation, race, ethnicity, immigration status).
Experience working with clients affected by significant challenges with behavioral and/or mental health.
Experience applying harm reduction principles in clinical care.
Experience working with highly traumatized populations, using trauma-informed principles of care.
Experience with working with patients living with HIV
Experience with wound care
Experience with gender affirming care
Fluency in English and an additional language (e.g., Spanish, Thai, Laotian, Vietnamese or Chinese).

Responsibilities

Serves as an integral member of the clinical and interdisciplinary Street Medicine team to provide wrap-around services/care for clients in a team-based care model.
Serves as a Lead Care Manager on the interdisciplinary Enhanced Care Management (ECM) Street Medicine team to provide wrap-around services/care for clients in a team-based model.
Adheres to all policies and procedures for the ECM care delivery model, including outreach, assessments, care plans and other related duties.
Performs nursing assessments for primary care patients in both non-traditional and traditional settings.
Collaborates with the multidisciplinary Street Medicine team in the development and implementation of complex care plans, including appropriate and timely follow up for transitions of care from acute care settings.
Provides leadership within a patient’s multidisciplinary care team to ensure progress towards achieving a patient’s care goals.
Emphasizes a relational care delivery model by seeing a patient in their lived environment to address the social determinants of health impacting a patient’s health and wellness.
Monitors acute changes in patient status to revisit care plans accordingly and develop transitional care plans if a patient is seen in an acute care setting.
Provides patient education on a variety of topics (e.g. HIV, diabetes, hypertension, asthma, nutrition, and other specific diagnostic procedures).
Provides team-based medical management according to defined algorithms for patients with chronic diseases.
Provides wound care services under supervision of providers and per clinical protocols as part of the Street Medicine team.
Performs initial and continued assessment of client health status, immunizations, and TB screening based on established protocols.
Administers adult immunizations, medications, and phlebotomy consistent with current guidelines and established protocols in both traditional and street/community based settings. Assists with medication adherence support.
Coordinates treatment plans/procedures for routine services such as HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), drug detox, and STI treatment.
Evaluates and manages routine medication refills and helps navigate prior authorizations according to established workflows for Street Medicine patients.
Participates in Street Medicine drop-in clinic as needed at the discretion of the Street Medicine team.
Participates in nurse drop-in clinic shifts to provide same-day nursing triage, nursing care per standardized procedures and established nursing protocols or per verbal orders from a clinic provider, or “flip” the visit to a provider visit if clinically indicated for all SFCHC patients.
Attends weekly multidisciplinary Street Medicine team case conferences, prioritizing high-needs patients to be seen by each program.
Works with clinical collaborators at local hospitals and community partners to connect unhoused people with the Street Medicine team and develop patient-centered care plans for patients engaged in the program. Collaborates with these same partners on transitional care plans for Street Medicine patients accessing services at these sites.
Documents appropriately in the electronic medical record.
Uses multiple electronic data sources to gather patient information and track ED or inpatient utilization across care systems.
Responds to medical emergencies in a timely fashion, under provider supervision, with clear delegation to clinic staff as appropriate.
Provides culturally and racially competent client care in a manner that is both non-discriminatory and non-judgmental.
Communicates effectively with clients/patients, clinic staff, the public at large and departmental staff in a non-discriminatory manner.
Covers clinical job duties of non-licensed staff when required by clinic management.
Links patients to appropriate internal and external medical, behavioral, and social services.
Must be able to travel on foot around the Tenderloin neighborhood and surrounding area.
Must be able to carry medical supplies in a backpack to patients within the community.
Other job-related duties as assigned.