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Registered Nurse
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Full-time
- The Community Care team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home.
- Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
- Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
- Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
- Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
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