The CKP Nurse Care Coordinators (RWNCC) are responsible for direct patient care activities relating to CKP patients across the health center. The CKP Care Coordinator’s functions include HIV adherence and educational counseling, facilitation of referrals, HIV counseling and testing, participation in maintenance of Ryan White electronic records and in quality management activities of the Ryan White program in addition to routine ambulatory nursing functions. The CKP Nurse Care Coordinator functions as an integral member of the CKP Interdisciplinary Care Team as well as the site nursing team at her/his assigned practice site(s).
As part of a clinical team, the CKP Nurse Care Coordinator works at the top of his or her licensure to enhance the safety, effectiveness, and efficiency of care through both the performance of professional nursing responsibilities and the delegation of technical and clerical functions as appropriate to medical assistants. The CKPNCC provides patients with both general and focused health education regarding preventive, chronic, and episodic health care issues, assumes responsibility, in collaboration with medical and behavioral health providers to coordinate care, support transitions between levels of care, and counsel, educate, and support patients in improving health status. The CKPNCC applies principles of advanced access, planned care and the chronic care model, and rapid cycle performance improvement using the PDSA approach at CHCI.
As a member of the CKP, the CKPNCC will also work closely with HCV infected and co-infected patients, as well as patients engaged in Suboxone (buprenorphine) therapy for the treatment of opiate addiction.
ROLE AND RESPONSIBILITIES
- Serves as the primary contact for Ryan White HIV patients at assigned site(s) with regard to antiretroviral and adherence counseling and other patient education, patient calls, prescription renewals, and home visits requiring nursing expertise. Available to counsel partners and family members where appropriate. Provides HIV Counseling and Testing services on-site as needed.
- Is knowledgeable with the Ryan White outcome measures and adheres to CHC’s HIV management protocols. The CKPNCC is familiar with the roles of all CKP staff and coordinates appropriately with other members of the team.
- Actively participates in CKP staff meetings and activities, including patient case review and coordination of patient care. Participates in HIV-related QM activities
- Maintains R.N.-level knowledge of HIV, antiretroviral and adherence management, LGBTQ healthcare, HCV, MAT. Attends regular training and education related to these areas of expertise.
- Establishes an ongoing and productive relationship with CKP providers and works closely with CHC Mental Health staff on clinical management. Serves as coordinator of the CKP Interdisciplinary Team and Interdisciplinary Team meetings at his/her site, including integration of Ryan White into the site’s overall practice. Collaborates closely with the HCV Nurse/Patient Navigator. Provides information and education about HIV risk reduction and availability of CKP services at his/her site.
- Participates as faculty in Project ECHO HIV/HCV and acts as a liaison and resource for provider participants.
- Provides education to patients infected or co-infected with hepatitis C virus and assist with medication adherence and side-effect management for patients undergoing treatment.
- Provides education and counseling to patients with opiate addiction; assist with medication adherence for patients engaged in buprenorphine therapy; using motivational interviewing techniques, assists patients in developing coping and problem solving skills.
- Support primary care of patients under planned care model, including pre-visit planning, daily huddles, and execution of nurse-led and nurse-assisted visits.
- Collaborates with primary care provider to identify needs for preventive care, evidence based chronic disease care, and care coordination.
- Provides general and specific health care education during patient visits and by telephone.
- Works with patients to identify and monitor self-management goals.
- Collaborates and coordinates care with other community based providers.
- Follows up on emergency room visits and hospital discharges.
- Assists providers with exams, treatments, and procedures as needed.
- Ensures safe, accurate, clinically appropriate collection, storage, and processing of all biologic specimens.
- Administers medications, including immunizations, at the order of prescribing provider and under standing orders as established by CHCI.
- Adheres to CHC protocols regarding documentation of medication, route, dosage, and information provided to patient.
- Monitors patient response to medication based on specific medication administered; detects, reports, and responds to any adverse reaction. Reconciles medications. Provides patient education as appropriate to the administered medication.
- Performs wide range of nursing activities as needed and after initial prescription by primary care provider such as wound care, catheterization, etc.
- Accurately documents all aspects of patient care in the medical chart on a timely basis.
- Schedules tests and referrals for specialty care on order of provider.
- Maintains strict infection control standards in accord with CHCI protocols and universal precautions TJC, OSHA and CLIA standards.
- Acts as a resource person for medical assistants regarding patient preparation, needs and procedures needed.
- Monitors and ensures follow up of all abnormal pap smear results, STDs, lead screens and other tests and screens performed at CHCI.
- Oversees the maintenance of supplies and equipment, ordering supplies as necessary.
- Maintains compliance with agency mandatory annual training (Patient Safety, Abuse, Age Based Competencies, EOC, Abuse trainings, etc.)
- Expert use of electronic health record to ensure timely, safe, confidential storage and retrieval of patient information.