Project Access of Durham County (PADC), a non-profit organization, provides access to donated specialty medical care and services to low income uninsured residents of Durham County and administers the Durham Homeless Care Transitions (DHCT) project. PADC seeks an RN to provide case management to clients with poorly controlled chronic illnesses as well as homeless persons being discharged from hospitals in need of follow up health care and other support services. This position will be directly supervised by PADC Executive Director and work closely with 5 other members of the care management team.
- Chronic Illness Care
Provide nursing case management to uninsured persons with poorly controlled diabetes
- Assess patient needs and establish 3 month care management plan to support improved health outcomes
- Communicate with primary care provider, pharmacy, and other health care or community partners
Provide education and training on chronic disease to care management team
- Homeless Transitional Care
Provide nursing care management to medically vulnerable homeless persons--
- Introduce program to patients and conduct assessment of patient needs and appropriate next steps, including need for short-term medical respite
- Coordinate with agency staff and primary care provider to facilitate effective transition
- Conduct transitional care follow up home or telehealth visits or practice encounters according to established protocol
- Develop overall care transition plan with patient, including primary care home, mental health and substance abuse services, assessment of disability and potential for employment, and housing options
- Perform medication reconciliation and chronic disease education
For patients needing medical respite--
- Identify primary care home and respite facility
- Make arrangements with respite facility to approve and receive patient
- Conduct in person or tele-visit within 48 hours of discharge
- Develop care plan with patient, including plans for discharge; re-visit as needed
Collaborate with care managers and housing specialists to meet resource needs of clients
- Document patient information and care management activity and use appropriate tools to assess patient activity and address barriers to care
Minimum Education/Training Job Requirements
RN (BSN preferred). Graduation from a state accredited school of professional nursing. Experience working with under-resourced communities. Knowledge of Durham community is helpful. Ability to communicate effectively to diverse populations including patients, staff and general public. Ability to work in the community, including non-traditional work settings such as clinic/hospital waiting rooms, street corners, or client homes. Understanding of mental health and substance use issues; understanding and experience with immigrant populations helpful. Bilingual (English/Spanish) preferred. Must have own transportation (car) and valid NC driver’s license.
Position offers health insurance (premium paid for high deductible plan plus contribution to Health Savings Account), dental insurance, and matching 3% contribution to IRA. 17 days paid time off plus 10 holidays.
TO APPLY: Please e-mail cover letter and resume to Sally Wilson, Executive Director, firstname.lastname@example.org. Phone 919-237-2356.