Case Manager, PATHways Program at the Comprehensive Care Clinic
Requisition Number 2008194
* Collaborates with the health care team to coordinate patient and family interventions across the continuum of care, removing barriers and promoting efficient and effective use of resources.
* Assists patients and families in establishing patient specific goals, both long term and short term.
* Facilitates appropriate follow up care and/or refers patients (within the designated patient population) to the appropriate next level or site of care.
* Serves in an advocacy role on behalf of patients, families, and caregivers to ensure safe, equitable healthcare provision.
* Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model.
* Assists in the nursing component of developing and meeting key Pillar goals including finance, satisfaction, clinical quality of care, innovation, and growth across the continuum of care.
The PATHways program is a nursing-led, interdisciplinary intervention designed to provide community-based and clinic-based care for patients failing to manage their HIV disease due to secondary burdens beyond their ability to control, such as childhood sexual abuse, HIV stigma, substance abuse, etc.
The primary responsibility of a nurse case manager on the PATHways team at the V-CCC is to provide intensive case management that includes:
* Care coordination with community-based HIV/AIDS Serving Organizations
* Community-based medical care under the direction of a medical provider
* Overcoming barriers by addressing social determinants of health such as stigma, abuse, health literacy, medication access, insurance navigation, transportation, housing, etc.
The Vanderbilt Comprehensive Care Clinic (V-CCC), a nationally-recognized HIV Center of Excellence and a Primary Care Medical Home, is located at Vanderbilt Health's One Hundred Oaks campus. The V-CCC provides care for more than 3,000 active outpatients living with HIV from Tennessee and adjacent states. The V-CCC has on-site psychiatric, adherence counseling, social work, and nutrition services. Patients with HIV/AIDS receive quality, comprehensive HIV care, regardless of their ability to pay.
We are seeking qualified nurses who have a heart for caring for marginalized patients and can work in a fast-paced environment and enjoy a collaborative team-based work setting.
The Vanderbilt Comprehensive Care Clinic is committed to providing high-quality, affordable medical care that treats the whole patient. Our services include:
* Medical evaluation and follow-up care
* Medical case management (assistance with third-party coverage and access to medical and dental care)
* Access to screening and clinical trials
* Full-service laboratory at Vanderbilt One Hundred Oaks
Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. It is a place where your diversity -- of culture, thinking, learning and leading -- is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.
Our Nursing Philosophy:
We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center's mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being.
Assesses and identifies patients with complex clinical needs that require a coordinated plan of care.
Develops case management plan that includes strategies or alternative interventions required to attain optimal patient and family specific outcomes.
Analyzes progress on the plan of care, identifies variances, and intervenes utilizing process improvement methodologies to remove barriers and progress care.
Integrates ethical provisions in all areas of the practice.
Demonstrates leadership skills and acts as the key information and education resource for the interdisciplinary team as related to caring for complex needs and securing appropriate services.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
CASE MANAGEMENT (INTERMEDIATE): - Demonstrates mastery of case management in practical applications for complex clinical care coordination. Possesses sufficient knowledge, training, and experience to be capable of successfully delivering results without requiring support and instruction from others. Able to train and educate by setting the example, giving instruction, providing leadership, and generally raising the level of performance of others while on the job.
RN ACCESS PATIENT EDUCATION (INTERMEDIATE): - Demonstrates mastery of patient education in practical applications of a complex nature. Possesses sufficient knowledge, training, and experience to be capable of successfully delivering patient and family education services without requiring support and instruction from others.
TREATMENT PLANNING (INTERMEDIATE): - Demonstrates mastery of treatment planning and possesses sufficient knowledge, training, and experience to be capable of successfully delivering treatment planning services without requiring support and instruction from others.
NURSING PATIENT ASSESSMENT & EVALUATION (INTERMEDIATE): - Demonstrates mastery of patient assessments and evaluations in practical applications of a difficult nature. Conducts primary care patient interviews and physical examinations. Conducts inquiry with a thorough series of questions when patients state an ailment or complaint in order to accurately identify and elaborate on the problem. Possesses sufficient knowledge, training, and experience to role model and coach less experienced peers.
EVIDENCE-BASED PRACTICE (INTERMEDIATE): - Demonstrates ability to integrate evidence from multiple sources and determine if a practice change should occur. Shares knowledge with peers and other clinical team members independently.
Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.
SUPPORTING COLLEAGUES (P3):
- Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
- Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.
DELIVERING EXCELLENT SERVICES (P3):
- Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
- Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
- Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.
ENSURING HIGH QUALITY (P3):
- Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
- Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
- Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.
MANAGING RESOURCES EFFECTIVELY (P3):
- Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
- Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
- Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.
FOSTERING INNOVATION (P3):
- Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
- Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
- Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.
Internal Number: 2008194
About Vanderbilt University Medical Center
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period.Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As th...e largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.
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