Central City Integrated Health is committed to enabling every patient in our community to thrive by building a collaborative multidisciplinary healthcare team. The Staff Nurse provides care to patients/families by assessing, triaging, planning and intervening on actual or potential health problems, including evaluating patient responses to care. These responsibilities also include patient/family education and health maintenance strategies. The Staff Nurse is a member of a designated health care team and collaborates, coordinates and guides team members in planning patient care and achieving goals. He/She must demonstrate knowledge of the principles of human growth and development, as well as chronic disease management and interpret data reflective of the patient's status to identify requirements relative to his or her specific needs. The Staff Nurse must treat within the scope of practice for the State of Michigan and must demonstrate the following personal and physical qualifications, which are essential functions of the position:
- Ensures all actions, job performance, personal conduct and communications represent the organization in a highly professional manner.
- Ensures timely, ongoing communication with the provider staff and care team(s) to identify high risk patients; maximizes coordination of care to reduce associated health risks.
- Ensures effective and efficient comprehensive transitional care management to prevent unnecessary readmission to the hospital and/or emergency department, including a follow up evaluation and medication reconciliation.
- Communicates with patients, patients’ family, PCP and care team post hospitalization to manage follow-up care as appropriate.
- Maximizes the effectiveness of patient office visits by reviewing care needs prior to the appointment (chronic disease protocol; preventive health protocol; follow-up patient counseling/education needs).
- Coordinates reviews of patients’ medication effectiveness with the medical team (adherence/patient understanding, expected impact and side effects).
- Leads team huddles to plan visit objective(s).
- Reviews lab results daily; discusses abnormal results with ordering provider.
- Assists patients in setting/maintaining self-management objectives; understands the correlation between physical health and behavioral health issues.
- Recommends interventions to modify behaviors associated with health risks; collaborates with the patient to determine meaningful treatment goals.