This position plans, coordinates, and implements all the Chronic Health Program at a facility and serve as resource by providing education as required to patients and staff. This position is the subject matter expert for disseminating information on chronic diseases.
Primary Duties and Responsibilities
Ensures that chronic health screening is performed at the intake screening.
Ensures patients are scheduled to appropriate clinicians (physician, physician assistant, nurse practitioner) for initial and follow-up care.
Educates inmates in medication side effects and the treatment and management of chronic medical conditions including diet and lifestyle changes.
Utilizes a variety of patient teaching methods to impart vital information about disease management to the chronic care patients.
Creates systems to maintain security while allowing inmate involvement in self-care. Oversees a basic KOP (keep-on-person) program (if allowed in the facility) for self-administration of oral medications and inhalers. Teaches inmates to perform self-blood glucose monitoring.
Is familiar with the treatment plan for all chronic clinic patients and actively manages the multiple elements of the plan to assure consistent compliance.
Reviews medication administration records for compliance, initiating diagnostic tests such as EKGs and pulmonary function tests, and checks lab values when they arrive. Shares significant results with the medical provider so that adjustments can be made to the treatment plan.
Obtains orders for any needed lab studies and coordinates all recent lab results, diagnostic reports and specialty consults and assures that all information is available and accessible at the time of the patient visit with the medical provider.
Keeps a detailed log of all chronic care patients and schedules lab, diagnostic studies, Provider and Nursing follow-up visits as directed by the treatment plan.
Communicates and coordinates activities with other staff members as part of the interdisciplinary treatment team.
Participates in quality assurance review activities.
Maintains detailed case records and official reports on clients as indicated. Charts and reviews treatment provided, makes recommendations and refers to clinicians as needed. Maintains statistics on number and type of inmates seen.
Provide patients with discharge instructions and facilitate community referrals.
Performs other duties as assigned.
Graduate of an accredited school of nursing required. Must have a current, unrestricted license to practice as a Licensed Practical Nurse (LPN) in the state the facility is located. Maintains a current copy of license on file at the facility at all times.
Two (2) years of direct work experience preferred.
Familiarity with pharmacological aspects of drugs.
Familiarity a variety of patient teaching methods for patient education.
Must possess competence in the performance of the following services: crisis intervention, medical emergencies, physical assessment, medical nursing care, and psychiatric nursing care.
Must have the ability to work without direct, immediate supervision in performing nursing diagnosis, and be able provide appropriate follow through treatment.
Ability to work with computers and the necessary software typically used by the department.