Home Visiting Perinatal Nurse Care Manager en PCC COMMUNITY WELLNESS CENTER

Description

The Home Visiting Perinatal Nurse Care Manager provides direct care and care management for all perinatal patients (pregnant patients and infants) at PCC. Conducts home visits to high-risk case load (of pregnant patients, and after delivery, their infant, though 1 year postpartum). Provides prenatal, postpartum, and infant wellness education, as well as lactation / infant feeding support. Maintains knowledge of community resources; delegates in-scope tasks to Perinatal Care Coordinator.

Qualifications

Functions as a triage nurse providing professional nursing care to pregnant and postpartum patients and children, especially through direct participation in prenatal, postpartum and pediatric care throughout the perinatal continuum. Activities include, but are not limited to, history taking, comprehensive assessments, physical assessments (vitals, etc), medication administration, lab/testing education and follow-up, etc. • Conducts monthly home visits to high risk prenatal and postpartum/infant dyad caseload, up to 50 per month as determined by manager. Provides education, screening, and connects with appropriate resources. Collaborates with perinatal care coordinator in scheduling, conducting, and documenting the visits in EHR and any necessary care management software. • In collaboration with PCH (Perinatal Child Health) fellows and faculty chairs, coordinate and conduct monthly case management meetings for assigned site(s). Complete follow-up care activities or delegate as appropriate to site Perinatal Care Coordinator • Provide coordination of care between patient visits ensuring compliance with the care plan as determined by internal and external perinatal child health care providers • Provide consultation and academic support to nursing staff, providers, residents, and attending physicians in the areas of perinatal health care coordination that may affect overall health outcomes including social determinants of health, substance use, and mental health concerns • Provide appropriate referrals for internal PCC and external services. Facilitate referrals to high-risk obstetric services and track completion of referrals and receipt of reports. • Identify and follow-up on all referrals made to ensure continuity of care and patient/family needs are met. • Maintain clinical expertise in perinatal care and identify clinical issues related to perinatal care at PCC. • Collaborates with Perinatal Nurse Care Managers at all sites to identify professional and clinical challenges related to perinatal & newborn patient care. 2 • Collaborate with multidisciplinary health team to develop an integrated care plan, especially through care management meetings, and provide accountability for follow-up of the care plan. • Provide multi-modal education targeting (but not limited to) nutrition, risk avoidance, warning signs, preterm and term labor, breastfeeding, depression, self-care, family planning, safe sleep for infants, infant nutrition and development, etc. Provide gestational diabetes education to patients with this diagnosis. • Coordinate and utilize patient education materials and care tools appropriately with all relevant patients at the assigned PCC site. • Follow-up through clinic visits, home visits, phone calls and mail, as appropriate. • Maintain accurate and thorough documentation of nursing care and perinatal services provided. • Ensure that all data and required statistics/information for quality assurance, utilization and funding requirements are forwarded to the database or maintained in any other way as directed. • Implement new/improved clinical practices at the assigned site. • Act as a perinatal/child health resource to the community, departments and clinical staff. • Attend regular departmental staff meetings and in-service training. • Perform other duties as required and assigned

Experience/Training: • Graduate of an accredited school of nursing. • 2 – 3 years clinical experience, preferably in perinatal/child health nursing, care/case management and/or community/public health for the underserved. • 2 - 3 years EMR experience preferred. • Constantly communicates with patients, families, and other healthcare providers. Must be able to exchange accurate information in these situations. • Ability to work collaboratively and strong commitment to accountability Certifications/Licenses: • Current and valid State of Illinois nurse’s license. • Current and valid CPR card. Physical Demands: • Must be able to remain in a stationary position 50% of the time. • Must be able to move around the clinic site 50% of the time. • Constantly operates a computer, computer printer, copy machine, and telephone Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another. • Ability to move as needed to perform necessary nursing skills such as wound care, injections, and other procedures. • Must be able to transport from one site to another. • Must be able to cover other shifts as necessary.

Special Job Characteristics: • Fluent bilingual in Spanish and English for sites with significant Spanish-speaking patient populations.