Community Health Nurse
Full-time
Full Time
Hourly
$30 - 33/hour
This position is responsible for assisting Native American Community Clinic (NACC) Community Health Department preventative care and chronic disease management grant programming and quality improvement projects through patient outreach and education.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Phone and mail outreach for population health management. Includes scheduling appointments and basic care coordination.
Generate population health reports for various preventative health and chronic disease management initiatives
Educate patients on timeline for preventative care screening and follow up including cancer screening, diabetes, cardiovascular disease, well child checks, asthma management and others.
Recruit for chronic disease management groups and preventative care events and programming.
Field Community Health Department referrals including diabetes education, diabetes prevention program, mobile medical services (mammogram and vision), asthma management, and colorectal cancer screening fit kit referrals.
Support grant specific program evaluation activities and incorporating findings to refine and improve program effectiveness to meet grant deliverables
Track attendance and reach required for each grant
Complete monthly reports for program and grant activities provided to Community Health Manager.
Assist with grant reporting as requested by Community Health Manager Core duties and responsibilities include the following.
Assist with the programs in purchasing and budget maintenance.
Work with grant/project evaluators and Community Health Manager to develop data and reports as required to fulfill requirements of program evaluation plans.
Maintain regular communication with project partners and with the project officer to fulfill grant requirements, including submitting regular reports, as required.
Support ongoing sustainability planning on behalf of Community Health Programs.
Play an active role on the outreach team. Other duties may be assigned.
GRANTS:
MINNESOTA DEPARMENT OF HEALTH (MDH): SAGE SCOPES GRANT & MINNESOTA CANCER CLINICAL TRIALS NETWORK: COLOCRECTAL CANCER SCREENING GRANT
Assist with identifying eligible patients for colorectal cancer screening outreach
Deliver colorectal cancer screening promotion and education for eligible patients through mailings and phone calls
Provide fit kit education and follow up for eligible patients
Complete MDH Sage Scopes enrollment forms and tracking for eligible patients seeking colorectal cancer screening
MINNESOTA DEPARTMENT OF HEALTH (MDH): ASTHMA GRANT
Conduct outreach to patients with asthma with elevated Asthma Control Test (ACT)
Administer an asthma control test via phone outreach for those with elevated and past due ACT
Provide education to each patient or that patient’s caregiver on how to use the Asthma Action Plan to guide asthma management.
Provide education on reducing home-based allergens and referring to home visiting asthma programs.
Complete spirometry for asthma patients
GREAT LAKES INTERTRIBAL EPIDEMIOLOGY CENTER (GLITEC) GOOD HEALTH AND WELLNESS IN INDIAN COUNTRY GRANT:
Increasing awareness of prediabetes among tribal members and health care providers/ health professionals
education and awareness of chronic disease prevention and management at urban Native American community events
engagement of current patients in regular screening of chronic diseases including diabetes
engagement of current patients in lifestyle support for diabetes prevention and prediabetes
clinical services to support prevention, detection, and control of high blood pressure and/or high blood cholesterol.
referral and engagement in culturally specific chronic disease prevention education and production.
Direct delivery of patient education and support
Increased patient engagement with at home monitoring, improved control measures
SUPERVISORY RESPONSIBILITIES:
This job has no supervisory responsibilities.
Nurse Outreach Program Manager
Full-time
Full Time
$80,000-92,000
SUMMARY:
The Nurse Outreach Program Manager will provide direct nursing care and oversight of nursing outreach functions in the community, as well as coordinate a team of nurses and harm reduction staff in the development and implementation of mobile healthcare services at a Federally Qualified Health Center. NACC’s nursing outreach program will provide preventive health and acute care services within a mobile unit, as well as within Southside Harm Reduction Services’ drop-in center, and in other outreach settings, focusing on serving people experiencing barriers to healthcare including homelessness and substance use.
DUTIES AND RESPONSIBILITIES:
Professional Nursing Care and Outreach-Based Care Coordination
Provide professional nursing care (including triage, assessment, intervention, evaluation) in varying community settings, prioritizing trauma-informed care principles and patient-led care plans.
Deliver skilled interventions including, but not limited to, wound care and assessment, foot care, medication and vaccine administration, phlebotomy, education, standing orders, and vital signs.
Conduct nurse-led visits through the utilization of standing orders.
Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.
Provide health services stationed part-time at Southside Harm Reduction Services’ harm reduction drop-in center. Work closely with Southside’s staff to coordinate care for Southside clients, and serve as a health-services resource to staff and volunteers of the drop-in space.
Utilize harm reduction strategies to address health concerns disproportionately affecting unhoused populations including HIV, hepatitis C, STIs, wounds, foot health, asthma, diabetes, substance use disorder, overdose risk, and behavioral health concerns. Provide harm reduction services including naloxone, syringe and safer use supplies and education.
Perform assessments of patient’s unmet medical, behavioral, and social care needs and support the care team in meeting these needs. Help patients navigate community resources and specialty care, as well as linkages to primary care when needed. Work to reduce barriers through follow-up, transportation support, appointment reminders, and other strategies. Provide advocacy on behalf of patients seeking outside care.
Work collaboratively with clinic staff to identify high-risk or out-of-care individuals. Offer mobile care coordination services and linkages to care as appropriate.
Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol.
Read and interpret patient charts and lab results. Review new labs and identify need for provider follow up. Communicate with provider as needed.
Assist patients in care transitions, such as entering or discharging from treatment, hospitalizations, respite programs, and shelters. Work with external service providers to ensure continuity of care.
Facilitate rapid access to HIV and hepatitis C care, PrEP, PEP, and buprenorphine for substance use disorder.
Support care plan and medication adherence through medication set up, delivery, and routine lab draws.
Program Management
In collaboration with Medical Leadership, lead a small group of staff in a transition from in-clinic to outreach-based health services.
In collaboration with Medical Leadership, develop policies and procedures to support mobile health services utilizing evidence-based practices and patient-centered care models.
In partnership with medical Leadership and Southside Harm Reduction Services, develop and implement health services for people who use drugs delivered out of a new community drop-in space.
Work in partnership with Medical Leadership and Quality Team to monitor QA, QI, and performance reports. Coach and mentor staff to address continuous quality improvement in clinical care, customer service, and outreach.
Supervise and lead the day-to-day work of clinical outreach staff.
Develop relationships with community organizations and individuals to ensure collaboration and partnership to advance program goals.
Communicate frequently and directly with team members on patient needs and direction of daily work and larger issues affecting the health status of homeless individuals.
Utilize staff teams within NACC to refer clients appropriately, including but not limited to the patient advocate, population health, MAT services, infectious disease treatment, and other teams.
Initiate and lead targeted ‘in-reach’ and outreach to engage, educate, refer, and connect out-of-care patients to integrated health care services.
Oversee the management of medication stock and clinic supplies; maintain an inventory system, including par levels for all medications and supplies; complete monthly medication inventory to ensure compliance with 340b audits; inventory expired medications and dispose appropriately. Document data, plans, clinical actions, client progress, response to care and other relevant patient information in EHR.
SUPERVISORY RESPONSIBILITIES:
Directly supervises employees within the Outreach Nursing Program.
Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws.
Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
QUALIFICATIONS:
Bachelor’s or master’s degree in nursing.
Public health nurse registration preferred.
Clinical experience in community health and outreach-based nursing.
Proven experience in program development, management, and evaluation.
Experience working with chemically dependent adults and knowledge of harm reduction principles
Basic competence in duties and tasks of supervising employees.
Excellent verbal and written communication skills.
Commitment to excellence and high standards.
Strong organizational, problem-solving, and analytical skills; able to manage priorities and workflow.
Ability to work independently and as a member of various teams and committees.
Acute attention to detail.
Ability to deal effectively with a diversity of individuals at all organizational levels.
Good judgement with the ability to make timely and sound decisions
Demonstrated ability to plan and organize projects.
Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.
Street Outreach Nurse
Full-time
Full Time
$70,965.05 - $114,204.97 annually
Description
Hennepin County Health Care for the Homeless is seeking a Street Outreach Nurse who will be responsible for leading panel management and care coordination for patients of the Health Care for the Homeless (HCH) Medical Street Outreach program. We are looking for someone who is skilled and experienced in working with individuals experiencing homelessness in unsheltered settings, to support the team’s response to the public health priorities of the opioid crisis and infectious diseases related to drug use (e.g. the current HIV outbreak among injection drug users and people experiencing unsheltered homelessness). In this role, the Street Outreach Nurse will meet with patients where they are: on the street and/or in encampments in the Minneapolis area to provide care with the goal of improving health outcomes for individuals affected by these public health priorities. Working closely with medical providers, this position will assess patient’s health care needs and provide care such as medication management, point of care labs, wound care, and vaccinations as well as connect patients to health care homes for ongoing care.
Hennepin County Public Health is committed to advancing health and racial equity. We recognize racism is a public health crisis. We are committed to change, and to co-creating solutions with those impacted to support communities where everyone experiences optimal health and wellness. Diverse voices are critical to this mission. We encourage you to join us in this work!
Current Hennepin County employees who refer a candidate hired into an open competitive position may be eligible for a $500 referral bonus. For more information visit employee referral program.
Location and hours:
This position is hybrid and will be performed both on-site at Health Care Homeless clinic sites, in street outreach with the outreach team, and remote as job duties require. Work hours will typically be Monday through Friday from 8 a.m. - 4:30 p.m. While this position is designated as hybrid, based on current requirements hires must reside in or relocate to Minnesota or Wisconsin.
New employees who are hired into remote or hybrid positions between January 2, 2022, to December 31, 2024, will receive $500 toward the cost of establishing consistent internet connectivity, payable upon completion of 6 months of employment.
About the position type:
This is a full-time, benefit earning position.
This position is internally classified as a Nurse, Staff.
Click here to view the job classification specification.
In this position, you will:
Work collaboratively with the HCH Medical Outreach Team in following the objectives as related to the public health priorities of the opioid crisis and drug related infectious disease work and do the following:
Engage with patients who are unsheltered or are adjacent to the unsheltered community who do not seek traditional methods of health care.
While building relationships and trust, promote harm reduction while identifying health needs, and assess readiness to engage in health care.
Offer focused street medicine through a trauma-informed and harm-reduction lens, which may also include the facilitation of access to social services including needs assessment, housing, case management, benefits, legal help, and assistance with basic needs.
Partner with HCH medical providers to help patients access medications specific to the public health priorities, primarily: medications for opiate use disorder, antiretroviral medications for patients living with HIV, pre-exposure prophylaxis for HIV, screening/treatment for sexually transmitted infections, and treatment of other infections related to drug use.
Collaborate with other community street outreach agencies and Hennepin County departments and participate with staff on broader county projects.
Participate in Quality Assurance and Quality Improvement projects for street outreach.
Collaborate with Outreach Supervisor to establish work plans and timelines, monitor progress, and evaluate results.
Document data, plans, clinical actions, client progress, response to care, and other relevant patient information in Epic and in compliance with statute and rules of confidentiality.
Need to have:
Graduated from an accredited school of nursing.
Possession of a valid license, in good standing, as a Registered Nurse, or a permit to practice, issued by the State of Minnesota.
CPR certification.
A valid driver's license and the ability to obtain a Hennepin County driver's permit to travel to various locations within Hennepin County.
Nice to have:
Experience working with:
Individuals experiencing unsheltered homelessness.
Advanced phlebotomy techniques.
Panel Management and Medical Case Management.
Indigenous populations/programs focused on providing healthcare to Indigenous people.
Individuals with mental health and substance use disorder.
Electronic medical record system, specifically Epic and/or a similar system.
Experience establishing outreach connections, program collaboration, meeting patients outdoors, and street outreach.
Ability to:
Work in interdisciplinary team.
Communicate both verbally and in writing.
Demonstrate understanding of cultural differences and the impacts of racism on service provision, organizational effectiveness, and on relationships with staff, partners, and those we serve.
Be a strategic, adaptive, and creative thinker.
Knowledge of public health approaches and practices.
Knowledge of the impacts of racism on health and the social determinants of health.
About the department:
Hennepin County Public Health’s vision is for all people who live, work and play in Hennepin County to experience optimal health grounded in health and racial equity. Our department works to improve the health of all county residents by addressing the social and environmental factors that impact their health and offering programs and services that help them to be healthy. We promote physical and mental health, prevent illness and injury associated with communicable diseases and environmental conditions, and reduce chronic diseases.
About Hennepin County:
Hennepin is the largest county government organization in Minnesota. Our employees work every day to improve the health, safety and quality of life for our residents and communities. All of our jobs align to one or more of our overarching goals -- that Hennepin County residents are healthy, protected and safe, self-reliant, assured due process, and mobile.
Our employees receive a combination of generous benefits and positive workplace culture not found at other organizations. This includes meaningful work that impacts our community, competitive pay, work-life balance, a variety of benefits and opportunities to grow. Learn more at The Bridge - select Guest.
Hennepin County envisions an organization where our commitment to diversity and the reduction of disparities is fundamental in providing excellent service to our community.
Your future. Made here.
This posting may be used to fill current and future vacancies.
This position will have access to systems or other documentation that contains HIPAA data.
Invitations to interview will be based upon an assessment of education and experience.
Final candidates may be required to pass a driver's license check, complete a drug test that may include testing for cannabis, and/or a criminal background check.
If you have any questions, please contact:
Rebecca Maddaus
Rebecca.Maddaus@hennepin.us