General Summary: The Senior Services Nurse will work closely with nursing and case management staff within Henry Street Settlement’s Senior Services division to identify and coordinate services for transitional care management, chronic care management, general behavioral health integration and home health visits to older adult clients.
PRINCIPAL DUTIES AND RESPONSIBILITIES
· Host daily ‘Talk to the Nurse’ office hours.
· Assess client’s overall health utilizing a health indicator survey, establish health goals and timelines, and monitor clients for goals achievement.
· Provide health education on preventative care, chronic care management, and other pertinent topics of interest to senior clients.
· Facilitate regular support groups for clients with specific issues (diabetes, pain, depression, vision loss, etc.).
· Screen and monitor clients for chronic disease including regular checks of clients’ blood pressure, weight, medication adherence, and blood glucose.
· Identify clients with multiple chronic conditions at increased risk for functional decline or death and coordinate health care services as appropriate.
· Identify clients for needed mental or behavioral health services through a team-based collaborative approach to care.
· In collaboration with Senior Services Case Managers, develop client health intervention plans with regular follow-up on progress toward health goals.
· Identify patients discharged from hospitals, outpatient observation clinics, skilled nursing facilities, and community mental health centers for follow-up care.
· Provide client referrals and registrations to Betances for primary care and care management.
· Provide oversight to ensure and maintain patient flow to providers and efficient discharge back to Senior’s residence.
· In collaboration with Senior Services Case Managers, visit homebound seniors to identify clients in need of clinical home care and make referrals as needed.
· Participation in Henry Street Settlement and Betances staff meetings
Knowledge, Skills and Abilities Required
· Excellent communication, interpersonal, organization, and leadership skills.
· Assertive, detail-oriented, and able to handle multiple tasks simultaneously.
· Intermediate computer proficiency in Microsoft Word and Excel.
· Bilingual (Spanish/English or Chinese/English) preferred.
Education and Experience Required
· NYS Licensed Registered Nurse with 5-7 years experience in a Primary Care Center or Ambulatory Center. Will consider comparable inpatient experience. BCLS certification required.
· BS/MS Nursing