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Registered Nurse – Recuperative Care (RN-RC)

At Virginia Garcia Memorial Health Center, we honor all members of our community and acknowledge the dignity of each person we serve. Our purpose is to provide high quality, comprehensive primary health care to the communities of Washington and Yamhill counties with a special emphasis on migrant and seasonal farm workers and a view to removing barriers to health care. We strive to provide an environment that welcomes and values the people we employ and serve.

If you are unsure whether you meet all the required qualifications for this role but are interested and passionate about this potential position, we encourage you to apply.

Job Summary: The Registered Nurse – Recuperative Care (RN-RC) provides admission screening and intake, care planning, case management, patient education and health navigation, and clinical care within the scope of practice, for patients being discharged from the hospital setting without stable housing for recovery. This position works under the direction of a VG Medical Director with a non-clinical employee to visit patients assigned to 10 beds within a larger homeless shelter located in Hillsboro for basic medical supervision and care coordination.

The Recuperative Care Program (RCP) is a new program in partnership with Washington County Supportive Housing Services and Greater Good Northwest to provide acute and post-acute care specifically for people experiencing homelessness who are too ill or frail to recover from an illness or injury on the streets or in emergency shelter, but who do not require hospital-level care or skilled nursing services. This position will be based out of the VG 7th Ave clinic and will require travel to the RCP program site in Hillsboro and may require travel to local hospitals for discharge planning.

Essential Duties and Responsibilities:

• Screen referrals from hospitals and coordinate with discharge planners to assess patient acuity, program requirements, and bed availability to determine appropriateness for RCP admission.
• Identify potential clinical and supportive service needs while within respite program.
• Proactively communicate with RCP participant's primary care team (VG or external) to facilitate early post-hospital contact.
• Obtain required consents and releases for coordination of care.
• Develop care plan based on patient goals and the reason for admission to RCP.
• Gather information for a clinical care plan including physical and psychological history and assessment; list of current medications, dosages, and allergies; vital signs; other pertinent information, such as laboratory or other test results.
• Identify discharge indicators and develop a discharge plan with patient.
• Participate in and facilitate multi-disciplinary care coordination meetings with appropriate providers (e.g., PCP, home health, pharmacies, specialty care).
• Coordinate with shelter case management to address SDOH and other non-clinical needs.
• Provide shelter staff education and support around basic medical knowledge as relevant for evening and weekend supervision of RCP residents.
• Huddle daily with RCP team to create and implement daily action plans, performing transition of care visits for patients being discharged from hospitals, following up with outside provider recommendations after outpatient visits and ensuring that treatment recommendations and medication changes are acknowledged and actualized.
• Facilitate patient access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies (as needed).
• Provide patient education and health coaching on topics including diabetes, hypertension, and other chronic diseases, including assisting patients with self-management goal setting.
• Educate patients on how to utilize after-hours number or daytime nurse triage to address immediate clinical needs and provide guidelines for when to contact RCP team or PCP vs. seeking emergency department care.
• Log vital signs and monitor for changes in health status as indicated by the care plan.
• Administer pre- and post-procedural or operative care, including minor wound care per discharge instructions, monitor for changes in health, and recommend follow-up services as needed.
• Support self-administration of medications and patient progress towards self-management of medications. Coordinate with clinical pharmacy where appropriate.
• Assist with prescription management and reconciliation in conjunction with clinical pharmacy where appropriate. Advocate for medication regimen simplification, as needed.
• Identify and implement strategies to support independence in health management.
• Document all clinical care provided during RCP stay.
• Administer medication or vaccines under protocol and administer oral, I.M. and I.V. medication as ordered by a provider.
• Perform laboratory procedures when necessary.
• Develop and follow standardized protocols and interventions appropriate to RCP based on common diagnoses in conjunction with medical director.
• Prepare patients for discharge from the RCP to their new housing locations.
• Remain available by cell phone during RCP visits.
• Perform other duties as assigned.
• Handle protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA Requirements:

The RN-RC uses PHI to answer patient questions about their medical problems or plan of care, to triage and schedule appointments for urgent medical problems, to relay information from the health care providers to the patient and to provider nursing visits at patients' homes. Applying the minimum necessary standard of HIPAA, the designated record sets to which this employee may have access includes scheduling, demographics, and view only patient account information in the practice management system, the complete medical record, including confidential sections. All employees are required to read the content of these records only to the extent needed to accomplish the assigned task.

Knowledge, Skills, and Abilities:

• Proficiency in English and Spanish, both written and spoken language preferred.
• Desire to work with complex patients including people who are houseless and who may be struggling with mental health and/or substance use.
• High level of skill in interpersonal relations and problem solving.
• High energy and self-directed individual with excellent interpersonal, problem solving, organizational and computer skills.
• Ability to take initiative to proactively organize and manage the responsibilities of the job.
• High degree of integrity and professionalism.
• Ability to work in challenging environments in the community.
• Ability to work as an integral part of a high functioning team.
• Excellent Customer Service skills.
• Commitment and alignment to Virginia Garcia's mission, vision and values.
• Valid driver's license, reliable transportation, safe driving record and insurance coverage required.

Education and Experience:

• Current Oregon RN License required.
• Previous experience working with people experiencing homelessness desirable.
• Prior experience with Epic preferred.

Behavioral Competencies:

• Accountability: Role model VG's mission, vision, and shared values
• Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations
• Teamwork: If someone needs help, help them
• Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work
• Confidentiality: Maintain strict confidentiality and respect the privacy of others
• Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work
• Respect: Demonstrate consideration and appreciation for co-workers and patients
• Communication: Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others

Physical Requirements:

• Percentage of time spent
• Standing: 10%
• Walking: 25%
• Sitting: up to 60%
• Lifting/Carrying: up to 15%
• Physically demanding tasks: Must be able to lift/carry up to 30 lbs. – supplies for home visits.
• Able to walk up to three blocks at a time and up/down up to three flights of stairs to perform home visits.

Working Environment/Physical Hazards:

• Work in well-lighted, ventilated environment
• Potential exposure to blood borne pathogens and hazardous chemicals

Equipment Used:

• Office Equipment
• Computer: to perform data entry and word processing
• Telephone, fax, copier, scanner, printer