Description:

Scope:

The Registered Nurse (RN) in the CAP/DA program is pivotal in conducting detailed assessments and coordinating care for disabled adults to facilitate their ability to live within the community and avoid institutionalization. This role demands a high level of expertise in nursing assessments, a thorough understanding of healthcare plans, and the ability to work collaboratively with a multidisciplinary team.

Expectations:

Comprehensive Assessment Duties:

Perform thorough initial and annual evaluations of beneficiaries' medical, psychological, and social needs.
Assess and document the beneficiaries' health status and care requirements, considering both chronic conditions and potential acute health issues.
Identify factors in the beneficiary's environment that could impact their health and safety, and recommend interventions or modifications.

Collaboration and Coordination:

Lead and coordinate discussions with a multidisciplinary team to ensure a holistic approach to care planning. Team members may include social workers, therapists, and medical specialists.
Integrate inputs from various healthcare providers to formulate comprehensive care plans that address all aspects of the beneficiary's health and well-being.
Facilitate communication between family members, care providers, and social services to ensure a collaborative care environment.

Care Planning and Implementation:

Develop detailed care plans based on assessment findings, outlining specific goals, interventions, and expected outcomes.
Implement care plans and monitor their effectiveness, making adjustments as necessary to respond to the evolving needs of beneficiaries.
Provide direct nursing care when required, and supervise interventions carried out by other healthcare staff.

Documentation and Compliance:

Maintain accurate and up-to-date documentation of all assessments, care plans, and beneficiary interactions to ensure compliance with state regulations and program standards.
Document all case notes in a clear, concise manner, ensuring they are accessible for audits and reviews.
Ensure all care activities are documented in accordance with professional standards and legal requirements.

Results:

Effective management of nursing care for disabled adults within the CAP/DA program, ensuring beneficiaries maintain or improve their ability to live in a community setting.
Enhanced safety and quality of life for beneficiaries through proactive health management and care coordination.
Prevention of unnecessary hospitalizations or institutional care through vigilant assessment and timely intervention.

Requirements:

Qualifications:

Graduate of an accredited school of Nursing, current North Carolina RN license required
Minimum of 3 years of experience in geriatric, disability, or community health nursing. (Prefered)
Ability to establish and maintain effective working relationships with administrative supervisors, with members of caseload and their families, and with care providers and various community organizations
Ability to express ideas clearly and concisely
Ability to plan and execute work
Demonstrated ability to perform comprehensive nursing assessments and develop person-centered care plans.
Excellent organizational, communication, and interpersonal skills, capable of leading a multidisciplinary team.
Proficient in using healthcare IT systems for documentation and care coordination.

Physical Demands:

This position involves sitting for extended periods while using a computer, including frequent stretching and reaching, along with verbal communication, hearing, and smiling. The role requires the capacity to stoop, kneel, bend, lift, push, and extend arms. The sense of smell is essential for patient care. Additionally, the job entails walking up stairs in patient homes, transporting supplies and equipment from vehicles to patients' residences, and significant amounts of driving.

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