Licensed Vocational Nurse

ENHANCED CARE MANAGEMENT(ECM)

Licensed Vocational Nurse

REPORTS TO: DIRECTOR OF NURSES

HOURS: FULL TIME

CLASSIFICATION: EXEMPT

SUMMARY: California Advancing and Innovating Medi-Cal (CalAIM) funds the ECM program; the program coordinates care by utilizing a person-centered approach to maximizing individuals' health and life trajectories. ECM services consist of a multidisciplinary integrated care team providing in-person care management and care coordination to ensure services are available from managed care providers for members who are frequent utilizers of health services and individuals experiencing homelessness.

The LVN is a vital member of the ECM team and works collaboratively with the ECM team to provide high-quality care management to members. The LVN will provide outreach and engagement to members in a field-based setting, at home and on the phone, engaging members in skilled therapeutic interactions to promote healthy behaviors, coordination of care, resource linkage, and behavioral health interventions within the scope of practice.

DUTIES: The following reflects essential functions for this job but does not restrict other tasks, which may be assigned:

Administration

· Gathers input from other ECM Care Team members to prioritize member cases for systematic population/caseload review.

· Facilitates and ensure recommendations are communicated across the health care team.

· Receives, identifies, and follows up on treatment and medication alerts.

· Attend staff meetings and consults with the ECM care team members about clinical concerns or questions, and provides educational training on chronic disease states, prevention, treatment, medications, and healthy living.

· Ensures smooth transition of care, coordination with hospitals for M1 or with IEHP transitions of care for M2, regarding member admission/discharges.

· Reviews CHAs (split role with BHCM) upon completion by other care team members.

Direct Service and Support

· Responsible for primarily working with a caseload of members with complex medical needs.

· Engages members and supports/encourages member activation towards achievement of health goals.

· Provided member and family education about chronic medical and behavioral health conditions improve health literacy.

· Works with members to identify health/wellness goals and incorporates these goals into Health Action Plans/shared care plans that facilitate communication among members and providers.

· Coordinate physical care management and care coordination relationships with external health care providers.

· Conducts medication reconciliation with input from the members PCP.

Documentation and Data Collection

· Supports ECM members with complex medical conditions and completes medication reconciliation in collaboration with pharmacy as available for all ECM- enrolled members.

· Tracks medical and behavioral health outcome measures in the web-based care management platform or equivalent platform.

· Tracks and assures required assessments and screenings are performed, including Comprehensive Health assessments and shared care plan.

SKILLS: Extensive knowledge of medical disorders (diabetes, hypertension, etc.) and treatment. Knowledge of psychiatric diagnosis and co-occurring substance disorders. Thorough knowledge of medical and psychiatric medications, side effects, and administration methods.

Knowledge of EBP’s such as Motivational Interviewing, Housing First, and Trauma Informed Care. Must have extensive knowledge of resources. Excellent verbal and written communication skills. Aware of protocol for reporting suspected abuses, neglect, or other dangerous conditions. Understanding of and sensitivity to multicultural communities.

QUALIFICATIONS: California LVN license. The required license MUST be current and unrestricted; a conditional, provisional, probationary, or restricted license will NOT be accepted.

Candidate must have two or more years’ experience in behavioral health, acute medical-surgical, home health, skilled nursing, or direct client services to homeless individuals diagnosed with a mental illness, chronic health conditions, and tri-morbidity.

Valid California Driver’s License and automobile insurance are mandatory as automobile travel is required throughout San Bernardino County by personal or company vehicle.

SUPPLEMENTAL INFORMATION: Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty. Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical

expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully. All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up is committed to providing quality services that adhere to the highest ethical standards and principles. All Step Up employees agree to adhere to the ethical policies and codes of conduct, as outlined in the Employee Handbook and those specified for this grant.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER