Population Health Nurse - Duke Primary Care - Henderson Family

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Primary Care

Pursue your passion for caring with Duke Primary Care, which offers family, adolescent, and internal medicine services as well as urgent, general pediatric, and virtual care at nearly 50 clinic locations across central North Carolina.

Duke Nursing Highlights:

• Duke University Health System is designated as a Magnet organization
• Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
• Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000 + registered nurses
• Quality of Life: Living in the Triangle!
• Relocation Assistance (based on eligibility)

Population Health Nurse - Duke Primary Care - Henderson Family

Summary

• The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations
• This role will perform disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc
• The Population Health Nurse functions as an integral part of an interdisciplinary team, ensuring excellence inpatient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community.

Work Performed

• Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures
• Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community
• Monitor system access to care, services, and treatment including linkage to the medical home
• Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
• Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process
• Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient’s understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change
• Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness
• Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care
• This will include navigating transitions of care – generally from hospital to home or community facilities
• Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s )
• Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention
• Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence based care.
• Facilitate Quality Improvement activities that educate, support, and monitor provider(s),regarding evidence based care for best practice/National Standards of Care (Adapted from CMSA, 2010)
• Utilize innovative nursing and population management tactics to support the patient throughout the continuum of care in order to promote quality, cost-effective outcome
• Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research
• Provide clinical experience in a preceptor role for student s attending institutions that have contractual agreements with DUHS.
• Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff
• This position may require home visits however; position specific details and duties are available upon request
• The work activity and patient acuity levels can create a stressful atmosphere

Knowledge, Skills and Abilities

• The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:-- Organized and motivated by a fast-paced environment
• Able to manage multiple tasks/projects simultaneously-- Proficient in review and assess needs quickly--Strong with the use of computer software tools and data files
• Comfortable with continuous change and self-initiating
• Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems dev eloped for care management and population based program metrics)

Level Characteristics

Additional job expectations include the ability to:

•  Maintain strict confidentiality-- Promote programs and services to community
•  Build effective and trusting relationships with patient/peers-- Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
• Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
• Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
• Use data to analyze trends and to verify data
• Self-directed and able to organize and manage multiple tasks/projects simultaneously
• Ability to promote programs and services to community
• Proficient in review of medical records and other patient care information

Minimum Qualifications

Education

BSN

Experience

3 years of nursing experience required

Degrees, Licensures, Certifications

Current RN licensure in the state of North Carolina required.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.