Public Health Nurse - Long Term Care

Job Summary

This position performs highly responsible and professional level nursing involving assessment, support planning, case management services, and eligibility determination for publicly funded long term care services and support programs for seniors and persons with disabilities. Work is performed in an office, institution, community, home, school, or community-based setting.

Job Description

ESSENTIAL DUTIES

• Utilizing the MnCHOICES Assessment tool, created by the MN Dept of Human Services, conducts a holistic assessment of client/family that includes the health, psychological, functional, environmental, and social needs in a culturally sensitive manner by using independent nursing assessment skills and professional judgement.
• Identifies the health and safety issues of clients and the impacts on the clients, as well as on their family members or other community members.
• Identifies clients' strengths, needs, motivations, and capacities for change.
• Analyzes assessment data and assists applicants in identifying relevant goals along with specific supports that will enhance clients’ abilities to meet goals and live in the least restrictive environment.
• Determines applicants’ risk of institutional care and their level of care according to state and federal criteria.
• Determines eligibility for home and community-based programs (AC, BI, CAC, CADI, DD, EW waivers, SILS, FSC, CSG Voucher respite and PCA) based on individualized client needs and wants.
• Develops and implements nursing intervention plans based on nursing diagnosis to insure achievement to timely client outcomes.
• Provides health consultation and education on individual, and community levels through direct client service, collaboration with other health care providers, and by participating in meetings/task forces, to plan for and ensure service coordination with community agencies.
• Performs/implements public health emergency response functions as trained and assigned within the federal, state, and county’s emergency response plans.
• Analyzes and interprets diagnostic evaluations, medical information, and assessment results to determine program eligibility and support decision making.
• Communicates state and federal program requirements, eligibility results, and availability of services to clients, their family members, legal representative, community members, and service providers.
• Provides services for clients in a trusting and therapeutic manner, performing functions required by federal and state laws and rules.
• Provides intake and/or assessment services to evaluate, plan, and implement services for clients.
• Works in partnership with individuals or families to develop individualized/comprehensive case plans; coordinates and directs service to assure implementation of plans.
• Ensures the safety of clients through the development of support plans, safety plans, and back-up plans; assists in times of crisis to influence positive outcomes.
• Assesses, plans, implements, evaluates, and collaborates with other professionals and organizations to provide for and promote the social status of long-term care and developmental disabilities populations.
• Regularly drives a vehicle to transport self to activities or appointments as the needs of service dictate.
• Provides education, skill development, problem-solving, and support to clients and their families to empower and enable them to live independently; advocates for clients to maintain quality services and programs.
• Flexibility in scheduling may be required to meet the needs of the clients.
• Performs professional level nursing creating rapport, trusting, helpful, and empowering relationships with clients to assist individuals in success w/decision-making and self-determination.
• Prepares and distributes detailed written reports/assessment summaries outlining plans developed as the result of conferences.
• Maintains working knowledge of federal and state laws and regulations and performs work accordingly.
• Identifies clients' and community's priorities and desired outcomes. Identifies strategies and resources to be used in attaining the outcomes. 
• Develops plans that use the least restrictive alternatives to ensure the safety of the client and of the community. Identifies resource allocation and cost-effectiveness of services outlined in the plan. Reduces fragmentation of services to the clients. 
• Ensures continuity of interventions and services to meet the client's needs. Arranges service agreements to ensure provider payments. Writes reports/assessments as required, as well as case notes to follow progress of clients and/or cases. Maintains program data in a retrievable format to support required administrative reporting. 
• Monitors and evaluates the appropriateness, effectives, and quality of services provided to clients.
• Identifies service gaps ensuring services are delivered within authorized budget.
• Provides crisis intervention/management when needed.
• Consults, informs, and educates different audiences via public speaking, social marketing, mass media campaigns, and the development of educational materials. 
• Creates and develops resources for clients, families, and others as requested, required, and or needed. 
• Collaborates with both internal and external resources. 
• Performs nursing services as assigned, such as, but not limited to: Immunizations,  health education, health prevention, and health promotion.
• Works the days and hours necessary to perform all assigned responsibilities and tasks. Must be available (especially during regular business hours or shifts) to communicate with other employees, supervisors, customers, vendors, and any other person or organization with whom interaction is required to accomplish work and employer goals.
• Performs other related duties as required or assigned.

MINIMUM QUALIFICATIONS

CASE MANAGER:
Public Health Nurse licensed under Minn. Stat. 148.171-148-285

MnCHOICES ASSESSOR:
Public Health Nurse licensed under Minn. Stat. 148.171-148-285
At least one year of home and community-based experience
Certification as a MnCHOICES assessor by the state of Minnesota before or within 1 month of hire.
Qualifications are outlined in Mn Statute 256B.0911
The incumbent must possess a valid driver's license and a reliable means of transportation for the performance of work responsibilities.

SUPERVISORY CONTROLS

The employee is under general supervision of the Social Work Supervisor and the Adult Services Manager. Supervisor allows considerable latitude for the exercise of independent judgment. The work is reviewed through case/clinical record reviews, peer reviews, case consultations, community or system wide initiatives, and possible co-visits with supervisor.

Work may be reviewed by the Adult Services Manager or Public Health Supervisor, when performing duties on behalf of the Public Health Department, for overall standard of performance. Lead Agency reviews, every 3 years, by DHS.

CORE COMPETENCIES AND ABILITIES

• Customer Service - Delivers government services in a respectful, responsive, and solution-oriented manner.
• Communication - Is always clear about what we're doing and why we're doing it.
• Collaboration - Works with partners – communities, schools, faith groups, private business, and non-profit agencies – to see that services are not duplicated but rather are complimentary, aligned, and provided by the partners who can deliver the service most effectively.
• Stewardship - Works proactively to make investments, guided by resident input, which will transform lives, communities, and government.
• Empowerment - Works with individuals and families to affirm strengths, develop skills, restore hope, and promote self-reliance.
• Resiliency - Fosters public preparedness and responds when families and communities face health and safety emergencies.
• Innovation - Takes informed risks to deliver services more effectively and learns from successes and failures.
• Knowledge – Knowledge of principles and theories of professional nursing.
• Knowledge of the function of other health and social agencies and community partners and their relationships to public health programs.
• Ability to assist in the development of plans, projects, and programs for public health preparedness and response.
• Promote a diverse, culturally competent, and respectful workforce.
• Demonstrate knowledge of conversational interviewing techniques and skills.
• Demonstrated knowledge of person-centered planning principles and practices and incorporate them into assessment and care plan development.
• Ability to prioritize, assess, and manage assessment workload.
• Ability to analyze medically complex case situations to evaluate the needs for support services.
• Ability to collaborate with the community and government agencies.
• Ability to establish and maintain professional relationships with public and private agencies, and with lay and professional persons.
• Ability to assess individual's and family's needs and to develop and implement interventions.
• Ability to communicate effectively, via written documentation, in person, virtually, or over the phone.
• Ability to make independent decisions within community health nursing practice standards.
• Ability to direct and supervise the work of others and provide input for peer reviews.
• Ability to keep detailed records, adheres to documentation guidelines, and prepares reports.
• Ability to speak, present, and interact in public arenas with composure, professionalism, and discretion.
• Ability to use MS Office software, technology and applications needed for the performance of essential duties.
• Ability to use appropriate discretion in dealing with matters of a confidential nature.

WORK ENVIRONMENT AND PHYSICAL DEMANDS

Typical characteristics of the regular, ongoing work environment of this position requires inside work, occurring both in an office and in the field within clients' places of residence, work, or other non-county location. The position is multi-task oriented and includes periods of stress when balancing the needs/demands of multiple clients. Incumbent may be exposed to various atmospheric conditions such as COVID, bed bugs, lice, fleas, bodily fluids, odors, dusts, pets, poor ventilation, fumes, etc. when working in clients' residences. Incumbent may be exposed to uncooperative, angry, sometimes hostile and socially inappropriate clients. Some evening or weekend hours may be required. 

Physical activities include sedentary to light work: Reaching, sitting, standing, walking, pushing, lifting, pulling, fingering, grasping, feeling, stooping, talking, hearing, seeing, and repetitive motions. Lifts and/or navigates up to 35 pounds on a routine basis in handling files and equipment necessary for performing the essential duties of the job.

SELECTION PROCESS

Selection for this position will be based on a minimum qualifications screening and rating of training and experience. Top candidates will be forwarded to hiring manager or supervisor for consideration for interview and/or additional assessments. Final selection will include a background check and approval by the County Board.