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- Observe safety and security procedures; determine appropriate | | actions beyond guidelines; report potentially unsafe conditions; | | use equipment and materials properly.
Registered Nurse - Honolulu, United States - Kalihi Palama Health Center
Description
| Primary Purpose:| | | | The person in this position is a member of the Patient Centered | | Health Care Home team and is responsible in planning, implementation | | and over-all care coordination and quality improvement activities for | | the patients with chronic disease.
S/he participates in research and | | other projects that enhance patient care | | Essential Duties:
| | | | Supports the Patient Centered Health Care home team in planning, | | developing and implementing quality improvement activities related to | | chronic disease. | | | | Manages patients with chronic disease by creating and implementing a | | health care plan and self-management activities | | | | Conducts follow up either through face to face encounter, | | telephonically and/or in writing | | | | Teaches and/or coordinates classes for patients with chronic kidney | | disease | | | | Work in concert with other teams to achieve the goals and objectives | | or Patient Centered Health Care Home | | | | Assists in developing policies and procedures related to chronic | | disease | | | | Ensures that KPHC's chronic disease initiative and the patient | | centered health care home team asserts changes based on the | | components of the chronic care model and KPHC guidelines and plans | | for improvements are implemented. | | | | Provides monthly report and updates to the member of the team, senior | | management team and to the QI/QA committee. | | | | Collaborates with the Depression and the Health Care for the Homeless | | Diabetes Team in planning and implementing improvements. | | | | Serves as a liaison for chronic disease to other health centers | | and/or other organizations | | | | Explores community resources and establishes partnerships to | | facilitate improvements. | | | | Provides oversight for the maintenance of the health plans population | | management registry using i2i Tracks, Coseva, Guiding Care and other | | population management tools | | | | Supports other multi-cultural projects to enhance patient care. | | | | Coordinates short term rojects as assigned | | | | Performs direct patient care and/or covers other departments as | | necessary. | | | | Administrative Responsibilities | | | | Assists the clinical operations coordinator in the coordination of | | day to day operations of the Patient Centered Health Care Home team | | | | Facilitates huddles and meeting as necessary | | | | Supports and supervises support staff working with him or her. | | | | Maintain an awareness of services offered through the clinic and in | | the community to serve client needs. | | | | Maintain awareness of legal and legislative issues that may impact | | service availability. | | | | Participates in clinic quality improvements activities. | | | | Work in concert with the patient centered health care home team to | | assess and modify quality improvement strategies. | | | | Maintains client confidentiality per clinic protocol. | | | | Develops and implements forms for data collection, tracking and | | documentation of activities and works with the adult medicine team to | | determine effective communication strategies. | | | | Work closely with other clinic staff engaged in activities or | | projects involving clients as it relates to chronic disease. | | | | Regular and reliable on-site attendance is required.
| | Other Duties:
| | | | Perform other related duties as assigned | | | |
| | | | Skills/Knowledge: | | | | Knowledge and skills in the delivery of community health nursing care | | | | Knowledge of Community Resources | | | | Ability to assess and plan in a multi-cultural context | |