This position manages the diabetic population at One Community Health (OCH) clinics. The Diabetes Care Registered Nurse (RN) or Register Dietician (RD) who provides intensive diabetes care and case management including management of medication and equipment needed to control diabetes. In collaboration with the Salud Team, the Diabetes Care Registered Nurse also assists and/or refers the patient for diabetes self-management education, counseling for co-morbid conditions, and behavior change support. The Diabetes Care Registered Nurse serves as OCH’s diabetes expert and resource for Primary Care Providers (PCP), team nurses, medical assistants, and other team members. This position participates in Quality Improvement initiatives related to diabetes management and is integral to the function of PCPCH teams.
Job Specific Functions/Performance Expectations
Embrace the philosophy, mission, and values of One Community Health.
Adhere to the guidelines and procedures of One Community Health.
Follow OCH-specific clinical practice protocols and guidelines applicable to chronic disease management.
Demonstrate understanding of the scope of practice of the Diabetes Care & Education Specialist position.
Demonstrate basic knowledge/understanding of the Patient-Centered Primary Care Home.
Demonstrate knowledge/understanding of care team roles and the DCES role within a PCPCH team. Support an integrated, multidisciplinary team approach to the care and support of patients, families, and communities.
Direct patient care:
Provide direct patient care for OCH patients with diabetes and associated co-morbidities.
Manage diabetes medications including titration and adjustments per protocol.
Communicate medication changes to PCP per protocol.
Manage diabetes devices including glucometers and continuous glucose monitors per patient need and PCP request.
Apply current evidence-based theory, practice, and standards of care per scope of practice and as outlined in relevant OCH policies.
Provide patient education per the Association of Diabetes Care & Education Specialists (ADCES) Diabetes Self-Management Education (DSME) Curriculum, American Diabetes Association (ADA) National Standards for Diabetes Self-Management Education and Support, and other evidence-based chronic disease standards.
Utilize motivational interviewing and other techniques to identify the patient’s readiness to change. Develop strategies for change.
Apply shared decision-making to promote behavior change.
Recognize and respect person/family-centered beliefs vs. health provider beliefs.
Recognize and respect cultural and socioeconomic challenges in person’s ability to self-manage their disease.
Select educational materials consistent with the patient’s age, literacy, and numeracy level, cultural or ethnic background, and physical or cognitive abilities.
Facilitate an individualized education plan that is focused on behavior change.
Collaborate with the patient and healthcare team to problem-solve difficulties in attainment of behavior goals.
Case management and care coordination:
Provide consultations for PCPs and care team members for patients with diabetes and co-morbid conditions.
Communicate the patient’s plan for ongoing self-management support to the PCP and other team members.
Provide clinical expertise to others on the healthcare team. Communicate population trends and health disparities to key stakeholders.
Advocate on behalf of the patient’s health care needs to the PCP and healthcare team.
Investigate and identify appropriate medication resources for patients based on socioeconomic and cultural needs.
Reviews cc’d patient charts requiring medication adjustment from the Salud Community Health Worker and provides feedback and direction as needed.
Health center diabetes resource:
Update staff on clinical developments in managing diabetes, including strategies relative to medications and behavioral changes.
Provide diabetes education and training to health center staff.
Serve as content expert for diabetes education and management.
Assess current trends from diabetes evidence-based research for application to practice.
Keep current on diabetes- and healthcare-related technologies/person-facing technologies, i.e. mobile apps for communicating with patients with diabetes and for data collection and analysis, continuous glucose monitors (CGM), and other wearable technologies.
Understand and utilize OCHIN Epic- Electronic Health Record (EHR)
Document all services provided in EHR, including accurate and detailed charting in each patient’s medical chart.
Complete and sign EHR documentation ideally within 48 hours.
Manage In-Basket in a timely manner.
Understand and utilize Outlook email and calendar.
Address emails and calendar invites in a timely manner.
Understand and utilize MS Office and all other forms of communication at OCH.
Other supporting job functions/expectations
Assist with data entry or gathering and quality improvement initiatives as directed.
Attend meetings, team huddles, and assigned trainings.
Identify own cultural humility and awareness as it related to chronic disease and self-care behaviors.
Critically appraise own knowledge, skills, and work practices and develop a professional development plan to address deficiencies.
Seek advanced-level educational opportunities in diabetes education and management and maintain individual training/education strategy.
Serve as a resource in curriculum, protocol, policy, standing order, and procedure development and maintenance, program planning, implementation, and evaluation.
Fluent bilingual English/Spanish skills
Associate Degree in Nursing or higher, OR
Bachelor's degree as required for obtaining Registered Dietician licensure.
Experience with diabetes patient education
2+ years of general nursing experience
Experience in primary care setting
Experience with adult chronic disease management
Experience with case management
Experience in community and/or migrant health
Registered Nurse (RN) with current Oregon License and current Washington License (or must be able to obtain WA license within 3 months of hire) OR
Registered Dietitian (RD) with current Oregon License and current Washington License (or must be able to obtain WA license within 3 months of hire).
Certified Diabetes Care & Education Specialist (CDCES) and/or Board-Certified Advanced Diabetes Management (BC-ADM) in accordance with the minimum qualifications set by the Certification Board for Diabetes Care and Education or eligible to take CDCES and/or BC-ADM exam once necessary hours are obtained.
Federally Qualified Health Center (FQHC) with clinics located in Hood River and The Dalles, Oregon.
We are focused on Preventative Healthcare! We want to be the place you come to stay healthy not just when you are feeling unwell.
YOUR PRIMARY CARE HOME
A Primary Care Home is a health center that is recognized for their commitment to patient-centered care. And just as it sounds, patient-centered care is all about you and your health! We also offer an integrated care model with Medical, Dental, Behavioral Health and support services offered under one roof.
ABOUT OUR MISSION
One Community Health's mission is to advance health and social justice for all members of our community.
But what exactly does that mean? When we talk about advancing health, we are here to address much more than the medical aspects of your life.
Social justice means all people have the right to live fulfilling lives, engaging in and contributing to society in positive, productive ways.
It's through this lens that we develop and practice our services, programs and culture of care. As our name confirms, One Community Health is a health care home for all people in our region. Anyone is welcome he...re, and we embrace and honor diversity, believing this makes society healthier and happier for everyone in the end.