Nurse Care Manager

Benefits

Additional Information

Job Description: I. Position Summary: HSL provides enhanced housing with services to seniors living in its four affordable housing locations and at partner housing sites, intending to improve quality of life and support independent living. At its core, enhanced housing with services is a proactive approach wherein resident services staff regularly and actively reach out to each individual resident to engage with them around their health and wellness, identify areas of need/risk, and provide intensive, individualized case management and support as needed and desired by the resident. This role is spread across five Brookline Housing Authority senior sites in Coolidge Corner. The Nurse Care Manager is a key member of the housing team working to support residents in living independently and safely for as long as possible by developing meaningful relationships with residents and providing support in a holistic way. The Nurse Care Manager collaborates with team members to engage residents in wellness assessments and health education, connect them to needed services, support in managing health concerns, coordinate care for residents returning from hospital or rehabilitation stays, document all resident care tasks, and partner with community providers to promote overall well-being. II. Core Competencies: Commit to the organization's core values of respect, dignity and empowerment. Able to form collaborative and trusting relationships with residents, families, and other staff. Work collaboratively with colleagues, both within and outside the HSL continuum. Listen attentively; speak respectfully; maintain confidentiality. Provide the highest quality of preparation and presentation. Committed to active outreach to residents, including engaging with them in their apartments, during programs, during meals, etc. Being 'out and about', visible and connected. Actively promote respect and inclusion for all residents and staff in a multicultural community. Have a "can-do" service mentality. Accept responsibility for all tasks assigned. Work independently toward achieving program goals III. Position Responsibilities: Partner with the wellness coordinator and the resident services team to provide comprehensive case management services to residents. Provide regular preventative outreach to all residents to check in on their needs and overall health, and develop trusting relationships with residents and their families. Conduct wellness assessments of residents to determine risk and needs. Actively follow up on all identified needs, including finding resources, making referrals, and ensuring residents are actively engaged in services. Evaluate resident medical concerns and support residents with decision making re next steps, e.g., calling PCP, going to urgent care, going to the ED or seeing a specialist. Coordinate with primary care physicians and specialists, hospitals, mental health, and other community providers. Ensure effective communication around changes in status, transitions, and service utilization. Active follow-up on all hospitalizations, rehab stays, and emergency room visits. Work with families, hospitals, rehabs, HSL Home Care, and/or VNA, ASAPs, and other providers to ensure safe discharges and ongoing services. Follow up regularly with at-risk residents to support adherence to health and wellness-related activities, medication,and treatment plans. Conduct and/or coordinate group and individual education sessions on health and wellness, including medication management. Track residents with special needs, such as dementia and mental health, and make appropriate referrals. Utilize collected data to identify, plan, schedule and implement focused programs, such as falls prevention. Support and educate housing staff members about common medical conditions and how to identify and communicate status changes. Participate in resident services team meetings, provider meetings and individual family meetings. Assist residents and family members with transition to other levels of care when needed. Assist with specific resident needs, such as taking vital signs, educating and assisting with Health Care Proxy and File of Life forms, arranging clinics for vaccines, and arranging other health-focused clinics, supporting residents in preparing for planned surgeries/medical tests. Document all work electronically in online software. Track residents with special needs, such as dementia and mental health, and make appropriate referrals. IV. Qualifications RN and 1 year of experience or LPN and 3 years of experience required. 3 years of experience in aging services preferred, home health experience, and dementia care a plus. Excellent triage and critical thinking skills are required, as well as the ability to handle difficult situations. Must have compassion for and a desire to work with a senior population. Excellent organizational and interpersonal skills, including the ability to manage multip