JOB SUMMARY
In collaboration with patients, families (as defined by the patient) and staff across Program Specific disciplines and departments, the Registered Nurse, Care Manager - Permanent Supportive Housing is responsible for managing all aspects of patient-centered care for patients with chronic illness. Works closely with the patient, the caregivers, physicians, and interdisciplinary health care teams to provide long-term care coordination and cost management for patients with chronic illness.

Permanent Supportive Housing (PSH) is permanent housing in which housing assistance (e.g., long-term leasing or rental assistance) and supportive services are provided to assist households with at least one member (adult or child) with a disability in achieving housing stability.

Essential Functions:

-Interact with patients via phone calls, medical, or social services appointments, in their home in collaboration with another team member, community spaces on PSH properties, and other locations per program guidelines, to bridge the gap between systems.
-Serve as a point of contact for patients enrolling in PSH Health Care Collaborative.
-Collaborate with PSH Health Care Collaborative partners, including Integral Care, Central Health, and ECHO on patient-centered care.
-Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, as well as appropriate use of resources.
-Empower patients and/or their families to be an engaged and active participant in their care management.
-Assess the state of patient and primary caregiver by conducting comprehensive interviews with patient and caregiver, specific to assigned Program.
-Develop and communicate (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice (for chronic illness) for designated target population per Program guidelines.
-Monitor the patient’s condition on a regular basis or as indicated in Program guidelines.
-Manage and coordinate all transitions between sites and providers of care or as indicated in Program guidelines.
-Educate and support the patient (family caregivers) as per Program guidelines.
-Facilitate patient access to community services.
-Provide direct nursing care to patients as indicated in Program guidelines, including Program specific SDO’s, and distribute medications and treatments according to accepted standards of care as applicable.
-Patient triage as needed.
-Optimize patient outcomes through the coordination of care with other providers by ensuring that patient care plans are in place.
-Proactively manage and follow-up with patients according to the specified care plan.
-Complete all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
-Attend daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the clinic.
-Attend seminars and maintain all licensure and/or certification requirements for continuing education and best practices.
-Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
-Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare
-Standard Operating Procedures and CommUnityCare Policies and Procedures.
-Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff.
-Interact respectfully and collaboratively, using a trauma informed care approach, with patients and their families, striving to develop favorable relationships with families.
-Collaborate with all members of the care team in providing patient-centered care.
-Perform other duties as assigned

Required Education: Postsecondary Vocational Award (higher degree accepted)-Graduation from an accredited school of nursing.

Preferred Education: Bachelor's Degree (higher degree accepted) in Science of Nursing (BSN)

Required Work Experience: 2 years of clinical nursing experience

Required Licensure/Certifications (upon hire): 

-Current license to practice nursing in the state of Texas

-Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current CPR certification during employment