Community Health RN (SDOH)
Steward Health Care Network
Steward Health Care Network
The "Care to Community Program" is a three to six month intensive wrap around program that integrates behavioral health services tailored for adult patients with substance use disorders along with care coordination for health-related social needs and care management for medical needs. The RN is an integral player in a multidisciplinary team composed of a social worker, community health worker, recovery coaches, transportation service providers, EMS providers, community partners and other experts in social determinants of health. The RN will manage program participants through coordination with the member's PCP and MAT providers
As a comprehensive part of general overall responsibilities, the RN will conduct assessments, medication reconciliations, monitor vitals, changes in conditions, and taking history in the community or in patients home.
Essential Duties include, but not limited to:
* Serves as a clinical conduit to PCP/Providers/EMS.
* Makes referrals to social work, CHW, MAT Provider, local EMS and/or additional community support services and resources as appropriate.
* Conducts in-home, community and telephonic patient assessment to identify barriers to care plan developed.
* As needed, coordinates effective transitions of care and effective handoffs to the next level of care across the entire continuum.
* Evaluates processes, identifies problems, and proposes improvement strategies to enhance the delivery of care for patients throughout continuum of care. Maintains awareness of key performance indicators/metrics. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions, and readmissions.
* Provide solutions to complex clinical problems through analysis, identification of programs, and opportunities for improvement to align with strategic plan of Steward Health Care Network.
* Utilizes available reports to proactively prioritize the needs of the high risk patients and coordinates interventions.
* Maintains required medical documentation for case management activities in the system's care management module (electronic medical records), according to the standards of work.
* Maintain confidentiality of all SHCN and patient related information and abide by all policies and procedures.
* Bachelor's degree required; Master's degree preferred.
* Graduate of a state-approved school of nursing; BSN preferred
Years of Experience:
* 3-5 year of experience, preferably with the Substance Use population
Work Related Experience:
* Experience working in a hospital and/or post-acute care environment with patients with substance use disorders strongly preferred
* Experience on a multidisciplinary care team strongly preferred
* Possess a current unrestricted RN license in the Commonwealth of Massachusetts
* Current Basic Cardiac Life Support (BCLS) certification
* Proficient in Microsoft Office
Job Reference #: 100024484