Reports To: Chief Medical Officer, Betances Health Center

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

Working Environment/Physical Hazards: This position will be working under clinical conditions, which involve exposure to blood and organic substances which are demonstrated biohazards. Incumbents are required to wear requisite protective equipment during specimen handling/processing.

Immunization:

• Staff member must meet immunizations requirements as stated in [CHC’s] immunization policy.

WORKING CONDITIONS/PHYSICAL EFFORTS REQUIRED:

Travel: Position will be based out of Henry Street Settlement and will require occasional travel to Betances Health Center’s network of facilities as needed.

Salary Range: Competitive according to industry standards.

Work Hours: Monday – Friday, 9:00am to 5:00pm

Percentage of time spent:

• Standing: 20%;  Walking:  25%;  Sitting:    50%;  Lifting/Carrying:     05%
• Physically demanding tasks: Must be able to life/carry up to 40 lbs. supplies