Chronic Disease RN

SUMMARY:

Reporting to the Nurse Manager, the Chronic Disease RN works collaboratively as a member of the patient care team to provide consistent, high quality, evidence-based care to patients within the health center. The Chronic Disease RN is accountable to perform in accordance with the standards set by the American Nurses Association, Massachusetts Board of Registration in Nursing, and the health center’s policies and procedures. 

GENERAL DUTIES & RESPONSIBILITIES:

The Chronic Disease RN is responsible for assessment, planning, implementation, evaluation and coordination of care for patients and their families within the health center. The Chronic Disease RN performs a variety of direct and indirect patient care activities. 
 

These include but are not limited to:

• Complies with all DotHouse Health policies, procedures, and standing orders
• Demonstrates ability to work as a team member; participates in orienting peers
• Completes accurate and timely documentation in the electronic health record
• Conducts Medicare Annual Wellness Visits with patients 65 and older
• Provides education for patients at risk of developing chronic diseases and with chronic diseases on topics such as nutrition, exercise, recognition and treatment of acute complications, and preventative health skills
• Helps patients at risk for and with chronic diseases with medication management techniques such
• Conducts disease course education with patients who are at high risk for or are currently living with a chronic disease
• Works closely with Diabetes and Hypertension clinic providers to provide ongoing medication management and education (medication administration, remote blood pressure monitoring, self-monitoring blood glucose, continuous glucose monitoring systems, nutrition, exercise, recognition of and treatment of acute complications and preventive health skills, disease course education)
• Conducts medication reconciliations with patients and provides med teaching
• Monitors patient’s response to therapy and revises plan as indicated through standing orders and provider guidance
• Provides skilled telephonic triage and assessment, education, collaboration and coordination of healthcare and community resources
• Administers medication, immunizations, treatments, and procedures as ordered; reviews and communicates test results per protocol
• Assists with management of urgent and emergent patient care situations within the health center
• Manages communication from internal and external sources
• Attends nursing and organizational meetings and participates in QI initiatives
• Provides safe, ethical, evidence based and culturally competent care
• Floats to other departments and functions as a Staff RN as need arises

REQUIRED SKILLS & COMPETENCIES:

Education: Graduate of an accredited school of nursing; BSN preferred

Experience: 

• 2 years’ nursing experience required

• At least 2 years’ experience in community health or ambulatory care setting, or diabetes care and education/counseling of patients with chronic disease preferred

• Active Diabetes Educator Certification or willing to obtain within 1 year of hire

Certification/Licensure: Valid LPN/RN license in the Commonwealth of Massachusetts. Current BLS certification.
 

Software/Hardware: Must be proficient and have a strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.)