The HNN is responsible for the oversight of all patients at CHC who are co-infected with HIV/HCV. The HNN will provide monitoring and tracking for all patients in the program in an effort to achieve the goals of the grant including; patient education, community engagement, provider recruitment, enhanced screening and linkage to care, and patient medication adherence. The HNN will also be responsible for participation in Project ECHO as faculty and providing HCV prevention education as needed to staff and patients.
ROLE AND RESPONSIBILITIES
Identify patients who have been lost to care after being diagnosed with HIV/HCV and work on re-engaging them in care.
Collaborate with Interdisciplinary CKP team an effort to provide the most comprehensive monitoring of HCV/HIV co-infected patients.
Develop and monitor a comprehensive service plan around the complex care management template for each patients enrolled in the program.
Coordinate patient and staff education around HCV prevention, infection and linkage to care.
Provide culturally humble care coordination to patients co-infected with HIV/HCV including individual education, group education, and family/caregiver education
Provide PrEP education to negative partners in an effort to reduce risk of infection.
Provide clinical support as needed to any CKP or CHC staff participating in care of HIV/HCV co-infected patients.
Work with CHC communications and CKP team to design and implement and outreach and awareness campaign designed to recruit patients for testing and provide education. This campaign will target African Americans as a group with a high risk of exposure.
Periodically review and adjust HIV/HCV treatment plan as decided by the clinical care team in an effort to provide the best practices in HCV treatment and services.
Provide intensive adherence education to patients.
Track and follow all related referrals for HIV/HCV co-infected individuals across the health center.
Provide additional recall and follow up to patients as necessary to maintain high rates of retention in care.
Bachelor of Science in Nursing (BSN)