Community Health Nurse

RESPONSIBILITIES

1. Carries out the organizations mission, philosophy, goals and objectives within guidelines

of policy and position function.

2. Interprets and implements the organizations philosophy to staff and members of the

community.

3. Assumes responsibility for assignments given, seeks supervision appropriately, and is

accountable for his/her actions by performing within the limits of his/her education and

experience.

4. Knows and conforms to the law governing the practice of professional nursing and

provides professional nursing care using all elements of the nursing process.

5. Assesses and evaluates the health care needs of patients and families with consideration

regarding physiological, psychological, social and environmental factors.

6. Identifies complete, accurate and logical Uniform Assessment System (UAS) for NY and

appropriate sequencing of diagnoses in collaboration with the PCP to maintain compliance

with state and federal regulations.

7. Maintains constant and ongoing communication with the assigned Care Manager in

regards to the participants health status, clarify questions regarding notes entered in the

EMR and discusses any and all other relevant information that needs to be used by the

Care Manager while representing the CHN in care planning and IDT meetings.

Collaborates with all members of the IDT in developing a comprehensive care plan based

on member-specific needs, physician orders, UAS-NY CAPS, other IDT assessments,

members specific parameters and identified goals that are respectful of member, family,

community and organizational resources.

8. Implements the nursing care plan and revises it whenever necessary by regularly

assessing, observing, and evaluating the patients condition, needs and response to care

and makes appropriate nursing judgments and decisions for care plan revision.

9. Initiates and applies appropriate preventative, therapeutic and rehabilitative nursing

procedures and techniques.

10. Administers medications and treatments as prescribed by the PCP. Ability to

independently perform skilled nursing procedures and techniques based on the changing

nursing needs that the member requires.

11. Teaches the patient and family/caregivers self-techniques whenever appropriate and

provides instruction regarding medication, diet, safety and treatment modalities in

accordance with the plan of care.

12. Recognizes and utilizes additional opportunities for health counseling/education with

patients, families and other caregivers and provides them with information that will

facilitate decisions regarding the promotion, maintenance and restoration of health.

13. Delegates responsibility appropriately, and supervises ancillary personnel in a manner

that will assure quality care and compliance with the care plan.

14. Evaluates for and promotes a safe environment for the patient and complies with National

Patient Safety Goals.

15. Completes, maintains and submits all required documentation that is timely (in compliance

with organizational policy) accurate, and relevant.

16. Meet all requirements for UAS-NY assessor function: timely completion within regulatory

standards, follow-up assessments, and significant change assessments as needed.

17. Reviews and confirms eligibility of member in the PACE program based on Nursing Facility

Level of Care (NFLOC) score obtained from the UAS-NY assessment. Confirms eligibility

of members with the members of the IDT.

18. Performs care coordination as part of their nursing visits to PACE members across all

settings of care. Collaborative care coordination to include internal (e.g., other IDT

members) and/or external health care professional (e.g., MD specialists, SNF staff,

hospital staff) in a manner that assures care plan coordination as well as continuity of care.

19. Performs periodic Nutrition Risk Screen (NRS) and coordinates member referral to a

Dietician when needed

20. Assumes responsibility for personal growth and development; maintains and upgrades

professional knowledge and practice skills through attendance/participation in continuing

and in-service education programs.

21. Meets organizational productivity guidelines.

22. As requested by supervision, participates in and assists with staff and student orientation

and development; participates in internal and external committee activities; and represents

the organization in the community.

23. Participates in performance improvement activities, as require