Job Title: Nurse Team Leader/Care Manager

Status: Exempt

Reports To: Clinical Director

Direct Reports: LVN, CNA, Per Diem Clinical Staff

Updated: August 2020

PRIMARY RESPONSIBILITIES:

Position has primary responsibility for the clinical care of 15 residents living in a 24 hr HIV/AIDS residential care facility. Position is also responsible for applicant screening assessments for both medical and psychosocial appropriateness and coordinates all resident intakes with the Clinical Director. The Nurse Care Manager provides support, supervision and managers the LVN/ CNA staff.

SPECIFIC RESPONSIBILITIES:

Ensures provision of excellent clinical care with optimal patient outcomes. Plans and implements care for all patients in compliance with providers’ orders, and state and federal regulations.

INTAKE ASSESSMENT AND CLINICAL CARE

Reviews potential residents’ medical & psychosocial needs for appropriate entry criteria by telephone and/or meeting.

Collaborates with Clinical Director to maintain frequent communication with referral source(s) and potential resident(s) regarding status of application.

Collaborates with Clinical Director to coordinate all activities related to admissions including chart face sheet, room preparation, and facility orientation.

Conducts medical and non-medical admission (in collaboration with Clinical Director)

Communicates initial medical assessment information to Clinical Director, Social Work-Case Managers, Therapist LCSW and other interdisciplinary team members.

Provides and/or supervises comprehensive nursing assessments of the physical and functional status of each new resident of facility within three days of admission and quarterly. Completes a CNA worksheet outlining the care and frequency of care to be provided each resident.

Conducts the medical intake evaluations of prospective residents, ensuring that their needs meet the scope of care and services provided at Maitri. Collaborates with Clinical Director to ensure that assessments and intakes occur at a sufficient pace to maintain 90% occupancy rate of HOPWA beds and 85% occupancy of all beds.

Provides and/or supervises patient care staffs’ ongoing and quarterly assessments of each resident's physical and psychosocial status and provides intervention as needed.

· Provides support to LVNs in addressing urgent care issues and medical management.

· Manages acute minor medical conditions.

· Triages major medical conditions for appropriate level of care.

· Perform other duties within nursing scope of practice as needed to reasonably assure quality care for Facility's residents.

CARE COORDINATION AND ADVOCACY

·In coordination with the Social Work-Case Management staff, directs the development and implementation of an outcomes-oriented Individual Service Plan (ISP) that conforms to the provider's plan of treatment. The ISP is completed within seven days of admission and updated quarterly and as needed.

· Communicate with attending providers, home health agencies, hospices, and other healthcare providers regarding the ISP, changes in health status, medications, health regimens, and other health-related issues as needed. Advocates for evaluation and/or treatment as necessary.

·Ensures medical orders are up to date and obtains signatures from community providers as needed.

In collaboration with the interdisciplinary team and community resources, coordinates resident discharges.

CLINICAL CARE/ADMINISTRATION

· Provide 24/7 clinical coverage as assigned

· Facilitate and manage LVN/CNA staffing within the facility and utilizing organization staff management system.

· Review, update, develop and implement sound clinical/medical policies.

· Develop and implement staff training for staff.

· Attend and participate in meetings to include Case Conference, Shift Change and Resident Appointments as needed and/or necessary.

· Provide leadership and support for maintaining standards of care and all elements required to maintain state license in good standing.

· In partnership with the Clinical Director, provide supervision and training for volunteer nurses.

· Review and approve LVN/CNA time cards and approve any/all over-time in partnership with the Clinical Director.

· Maintains strategies, policies and practices to assure adequate infection control within the facility.

· Provides clinical support, training and appropriate interventions related to COVID-19 and maintaining the safety of the facility.

DOCUMENTATION

· Documents all RNCM interventions and/or communications in the patient medical records.

· Maintains an updated medication lists for each resident and notifies resident’s primary care provider of side effects and other issues related to the medication regimen.

· Coordinates and monitors the documentation of medication assistance as specified in the Maitri Policy and Procedure Manual, in compliance with RCFCI regulation.

QUALITY MANAGEMENT

· Participates in the development and ongoing performance improvement projects of the Maitri Quality Management Plan.

· Interfaces with the Maitri Program Committee, the Clinical Director and volunteers to maintain clinical excellence.

· Regulatory Compliance: Responsible for compliance with Residential Care Facility for Chronically Ill/AIDS (RCFCI) regulations through the California Department of Social Services, as well as State Department of Industrial Relation, Division of Occupational Safety and Health, Blood borne Pathogens Standard.

COLLABORATION

· Collaborates with the Maitri management team to assure high quality and cost-effective care for Maitri’s residents.

SCHEDULE:

· Ability to work a flexible work schedule, including weekends, dependent upon the needs of Maitri.

· Ability to be on call as needed dependent upon the needs of Maitri.