Location: Medford,OR, USA
Housecall Providers Providers is a Portland area nonprofit organization and one of the largest providers of medical care exclusively in the home in the Western United States. We are proving every day that in home medical services for homebound and chronically ill patients can improve health outcomes, increase patient comfort, reduce health care costs and increase provider satisfaction. We are a proud part of the CareOregon family of health organizations.Our MissionImproving lives by bringing health care home.Our VisionTo sustainably transform home-based medicine so all homebound adults and those living with serious illness have access to care that improves their quality of life.Our ValuesCompassion and respect, authentic relationships, collaboration, courage, social justice.Diversity StatementWe embrace the diversity of our employees, patients, and those who care for them. Through awareness and advocacy, we are working to create health equity by recognizing and reducing barriers that affect non-dominant groups within Housecall Providers and our communities at large.The quadruple aim is real at Housecall ProvidersIn home medical care for homebound patients is proven to increase patient comfort, improve health outcomes, reduce health care costs and increase provider/care team satisfaction. Housecall Providers has saved Medicare millions of dollars, while providing better care to our patients, ensuring greater patient comfort, improved health outcomes and care team satisfaction. With the population aging, more people are suffering from multiple chronic conditions and degenerative diseases. This trend will continue as roughly 10,000 baby boomers a day enter the Medicare system.If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.Job TitleRegistered Nurse – Advanced Illness CareDepartmentHCP Advanced IllnessExemption StatusNon-ExemptRequisition #24628Direct ReportsN/AManager TitleAdvanced Illness Care ManagerPay & BenefitsEstimated hiring range $52.64 - $64.35/hour, 5% bonus target, full benefits.www.careoregon.org/about-us/careers/benefitsPosting NotesThis community-based position has the opportunity to move to a 4/10 schedule after training. The training schedule will be M-F, standard business hours. The position will start at 0.6 FTE for the remainder of 2024 (after training) and will increase to 1.0 FTE as of 01/01/2025.Job SummaryThe Advanced Illness Care (AIC) Nurse is focused primarily on a defined panel of high-risk patients. They participate as part of a multidisciplinary team to improve outcomes by enhancing community-based support. The AIC Nurse works with patients, their families/caregivers, as well as with members of multidisciplinary teams (MDT) across the continuum of care. These patients have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The AIC Nurse provides support and care for patients in various settings including: all types of patients' home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings.The AIC Nurse will support patients by offering real-time communication and coordination of care across all clinical settings, engaging the provider as a core member of the team to optimize symptom management. The AIC Nurse educates, counsels, and supports individuals, assists with longitudinal advanced care planning, and comprehensive transitional care. The AIC Nurse will achieve this with a trauma-aware and trauma-informed approach to address the multiple challenges that many CareOregon members face. This role does not direct or lead the care planning process; rather, it contributes to a multidisciplinary care planning process.Essential ResponsibilitiesProvides direct patient care support in a variety of settings for advanced illness patients utilizing palliative care principles, trauma informed care, motivational interviewing, and case management strategies.Drives the medical aspects of the care plan, including optimizing symptom management and coordination of medical and social services as well as addressing social determinants of health.Utilizes evidence-based guidelines and best practices related to disease specific assessment and interventions.Closely partners with the patient's providers and other members of the MDT across the continuum to facilitate care that meets the individual's personal needs, values, and preferences and improves outcomes.Uses evidence-based approaches to patient education regarding member's health status, disease state, red flag symptoms, symptom management, medication management and self-management strategies.Communicates and coordinates with patient's providers across the continuum of care to facilitate care that meets their personal needs, values, preferences to ensure care is coordinated and consistent with patient's goals of care.Demonstrates a person-centered approach in working with patients by respecting their self-determination and autonomy and exploring their ambivalence by utilizing Motivational Interviewing principles.Engages patient and family in advance care planning which includes discussions about goals of care and answering general questions about POLST forms and Advanced Healthcare Directives. Assists patient with documentation if requested.Plans, participates and/or facilitates care conferences during which advanced illness patient needs are discussed and evaluated and plans of care are developed and/or updated.Participates in IDG meetings as required.Collaborates with members of the healthcare team, CareOregon benefit specialists, vendors, and social services to enhance patient satisfaction, to conserve time and resources, and identify barriers.Assists clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) primary residence to hospital or skilled nursing facility and back. Assist with placement if needed.Assists in mentoring newly hired staff; may provide coaching and training.Provides timely and effective documentation including data collection.Actively participates in the development and implementation of the AIC program.Identifies and addresses organizational, cultural, and other barriers to best practice strategies.Serve as an ambassador for CareOregon and Housecall Providers at all times.Organizational ResponsibilitiesPerform work in alignment with the organization's mission, vision and values.Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.Strive to meet annual business goals in support of the organization's strategic goals.Adhere to the organization's policies, procedures and other relevant compliance needs.Perform other duties as needed.Experience and/or EducationRequiredCurrent unencumbered license as a registered nurse in the State of OregonMinimum 2 years' experience working as an RN in one or more the following areas: Home Health, Hospice, Palliative Care, Community Health, Hospital Care Management, Behavioral Health/Chemical Dependency, or Primary Care/Specialty Care clinicsCPR certification at hire or within 6 months in positionValid driver's license, acceptable driving record, and automobile liability coverage or access to an insured vehiclePreferredBachelor of Nursing degreeExperience working with a diverse community of individuals whose health has been impacted by social determinants, trauma, and marginalizationExperience utilizing motivational interviewing techniques, and trauma informed interdisciplinary approach to careKnowledge, Skills and Abilities RequiredKnowledgeKnowledge of impact of generational poverty and other social determinants of health on clients' ability to develop and follow self-care goals to improve health outcomesFamiliar and comfortable with a person-centered approach to communication, education, and care planningComfortable supporting patients at the end of their life; including facilitating, evaluating, and coaching advanced care planning conversations performed by AIC team or other CO programsKnowledge of current evidence regarding palliative interventions, and best practice and can disseminate knowledge to othersKnowledge of community resources to support a complex, vulnerable populationFamiliarity with electronic health record applications; comfortable learning new systems, if neededSkills and AbilitiesAbility to be sympathetic to a member, family or caregivers needs, and be able to engage people in various states of pain, trauma, and tragedyAbility to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients' multidisciplinary needs, developing health goals, and communicating with providersAble to work independently and make decisions appropriate to the situation in a complex and rapidly changing environmentAble to clearly and simply talk about AIC support and recognize the importance of health literacyMakes referrals to established CareOregon and community programs as deemed appropriateActs as a role model to advanced illness and palliative care teams for professional behavior, appropriate work ethic and appropriate boundariesExcellent communication skills including verbal and written communication in the form of presentations, meetings, emails, reports, networking, and conversationSkilled in having advanced care planning conversations is strongly preferredMaintains professional relationships with provider community and internal and external customers while identifying opportunities for improvementAdvanced computer application skills including Microsoft office and internet browsers/applicationsAbility to adhere to organizational standards, policies, and proceduresAbility to work effectively with diverse individuals and groupsAbility to learn, focus, understand, and evaluate information and determine appropriate actionsAbility to accept direction and feedback, as well as tolerate and manage stressAbility to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/dayAbility to pinch small objects for at least 3-6 hours/dayAbility to stand, walk, sit, bend, push, pull, crouch, crawl, reach, and climb stairs for at least 1-3 hours/dayAbility to operate a motor vehicleWorking ConditionsWork Environment(s): ☒ Indoor/Office ☒ Community ☐ Facilities/Security ☒ Outdoor ExposureMember/Patient Facing: ☐ No ☒ Telephonic ☒ In PersonHazards: May include, but not limited to, physical, ergonomic, and biological hazards.Equipment: General office equipment and/or mobile technologyTravel: Requires travel outside of the workplace at least weekly; the employee's personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.Location: Employees assigned to see members and patients in Columbia or Tillamook counties are required to live within 15 miles of their county assignment.Schedule: This position may occasionally require more than 8 hours per day.Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.Veterans are strongly encouraged to apply.We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.Visa sponsorship is not available at this time.