Wellness Nurse

A. Position Location/Pertinent Information

The Wellness Nurse is responsible for the general health and well-being of the clients with whom he/she supports.  The Wellness Nurse will provide health education, assessment and survey completion to clients monitored under the PCORI project. 

Location:

Human Services, Inc.
520 E. Lancaster Avenue
West Chester, PA 19380

FLSA Status: Full-time/Permanent/Exempt

Work Schedule: Monday through Friday 9:00am to 5:00pm

B. At-Will Employment

Your employment is at will. This means that you or Human Services, Inc. may terminate your employment at any time, for any reason, with or without notice. Nothing in this job description or in any oral or written statement shall limit the right to terminate employment at will.

All employees will adhere to Recovery Principles as employees of Human Services, Inc. (See attached document). Staff will participate in annual Recovery training and will utilize Recovery tools in the provision of services such as Personal Medicine, Power Statements, Common Ground, community integration and natural supports.

C. General Duties/Responsibilities

1. Reach out to Tier 1 members within 60 days of implementation. 
2. Update each client’s demographic, medication, diagnoses and any other pertinent information in the person’s Electronic Medical Record (EMR).
3. Be available as a consultant to other team members.
4. Participate in the physical and behavioral health learning collaborative.
5. Participate in the Wellness Nurse Learning Community.
6. Provide education about Wellness program, resources and disease related topics.

D. Identify Individuals with Significant Physical and Behavioral Health Needs

1. Review registry, data from hospital discharges for behavioral health and physical health admissions.
2. Complete medication reconciliations.
3. Assess the person clinically to see if the problem that precipitated hospitalization has been addressed and resolved. 
4. Assess each person’s clinical acuity both physically and behaviorally. The WN can refer the person for more specific physical or behavioral health care if needed.
5. Complete a Wellness Assessment Plan and create health goals and assure follow up is occurring.
6. Assure there is collaboration between the PCP and Psychiatrist regarding physical and behavioral concerns and use the Wellness Coaching process. 
7. Assure the person has been seen by their PCP within the past 6 months and review the list of medications for the person at the last appointment. 
8. Measure vital signs and record and update wellness registry. 
9. Assess guideline specific monitoring (weight/BMI, waist circumference, BP and labs for SGA’s.  Alert psychiatrist if monitoring is due. 
10. Assure that Tier 2 individuals are engaged in the Wellness Assessment process with an Health Nurse within 60 days of implementation. 
11. Be available to the HN for case consultation for any specific physical and behavioral Support Wellness assessment and goal planning being done by the HN with Tier 2 individuals.

D. Identify Individuals with Significant Physical and Behavioral Health Needs

1. Determine whether there is a need to consult with the HN regarding the person or whether the person needs direct wellness assessment.
2. Consult with HN as needed and monitors wellness coaching process to make sure assessments and goal setting are completed. 
3. Direct Wellness and planning including completing wellness planning tool and developing Wellness plan. 
4. Review behavioral and lifestyle risk factors for CVD. 
5. Ensure that weight, physical activity and smoking cessation (if applicable) have been addressed. 
6. Assess patient’s motivation to engage in treatment for smoking cessation. 
7. Inform patient’s Therapists/Psychiatrist for further management.
8. Appraise on going wellness efforts and provide education as necessary. Problem solve emergent issues as indicated. 
9. For Case Consultation on wellness planning and assessment; review wellness and assessment and planning
10. Assure PCP has risk factor assessment, V-S weight, BP, BMI, tobacco use (Obtain ROI first)
11. Review person’s CVD risk and any other major medical illness. 
12. Determine if person had appropriate lab tests and other supportive health screening. 
13. Discuss options for supporting a wellness plan with the HN and provide follow up and supportive education as needed. 

Recovery Principles

Human Services, Inc supports the vision of recovery for all those who experience mental illness. All staff of Human Services will utilize the Recovery principles to guide their interactions with clients and their families in the provision of services.  In partnering with clients, all staff will support and facilitate the use of Recovery tools that have proven effective in achieving the goal of recovery.

HOPE: a focus on wellness, health and hope.
CHOICE:  recognition of the client’s choice in all aspects of service delivery.
INDIVIDUALITY: being responsive to the particular individual’s needs and wishes.
PEER SUPPORT: the inclusion of peers and community supports in the planning of services.
PERSONAL RESPONSIBILITY: recognition of the inter-dependence between clients, providers and community supports as experts in their respective arenas.
COMMUNITY FOCUS and INTEGRATION: recognition and integration of an individual’s need for housing, employment, education and leisure activities from the outset of treatment planning.
RECOVERY PROCESS: service planning that reflects the view that recovery is individualistic and differently paced for different people.

I have reviewed the above and agree to adhere to these principles as an employee of Human Services, Inc.

Staff signature  ___________________________________________________________

Date  ___________________________________________________________