Population Health Nurse - Duke Primary Care - Midtown - Raleigh, NC
Duke University Health System
Location: Raleigh, North Carolina
Internal Number: 218829
Duke Primary Care
Duke Primary Care Duke Primary Care is a broad network of community-based clinics that offer family medicine, internal medicine, pediatric, and urgent care services. With 400 providers in nearly 50 locations, Duke Primary Care is the largest primary care network in the greater Triangle. Our network saw more than 750,000 patient encounters in fiscal year 2021.
Our Duke Primary Care clinics provide personalized care for adults and children, from sick visits to preventive care, health screenings to immunizations, and annual exams to chronic disease management. Select primary care clinics also provide behavioral health, diabetes education, pharmacy, and other population health services. Duke Primary Care clinics are accredited and designated a Primary Care Medical Home by The Joint Commission.
Our Duke Urgent Care centers offer evaluation and treatment for minor illnesses and injuries 12 hours a day, seven days a week when a patientâ€™s primary care provider is not available. Services also include certain physical exams and vaccinations. A pediatric specialist is available at select locations. Patients can walk in to one of our nine urgent care centers located throughout the greater Triangle or can schedule a virtual visit to receive care from the comfort of home.
Duke Nursing Highlights:
Duke University Health System is designated as a Magnet organization
Nurses from each hospital areconsistently recognized each year as North Carolina's Great 100 Nurses.
Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
Duke University Health System has 6000 + registered nurses
Quality of Life: Living in the Triangle!
Relocation Assistance (based on eligibility)
Population Health Nurse - Duke Primary Care - Midtown - Raleigh, NC
The Population Health Nurse is responsible and accountable for clinical expertise for specific complex patient populations
This role will perform disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc
The Population Health Nurse functions as an integral part of an interdisciplinary team, ensuring excellence inpatient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community.
Provide specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures
Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community
Monitor system access to care, services, and treatment including linkage to the medical home
Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process
Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change
Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness
Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care
This will include navigating transitions of care - generally from hospital to home or community facilities
Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s )
Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention
Advocate for patient(s) and supporting provider(s) to ensure delivery of appropriate, evidence based care.
Facilitate Quality Improvement activities that educate, support, and monitor provider(s),regarding evidence based care for best practice/National Standards of Care (Adapted from CMSA, 2010)
Utilize innovative nursing and population management tactics to support the patient throughout the continuum of care in order to promote quality, cost-effective outcome
Participate in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research
Provide clinical experience in a preceptor role for student s attending institutions that have contractual agreements with DUHS.
Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff
This position may require home visits however; position specific details and duties are available upon request
The work activity and patient acuity levels can create a stressful atmosphere
Knowledge, Skills and Abilities
The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:-- Organized and motivated by a fast-paced environment
Able to manage multiple tasks/projects simultaneously-- Proficient in review and assess needs quickly--Strong with the use of computer software tools and data files
Comfortable with continuous change and self-initiating
Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems dev eloped for care management and population based program metrics)
Additional job expectations include the ability to:
Maintain strict confidentiality-- Promote programs and services to community
Build effective and trusting relationships with patient/peers-- Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
Use data to analyze trends and to verify data
Self-directed and able to organize and manage multiple tasks/projects simultaneously
Ability to promote programs and services to community
Proficient in review of medical records and other patient care information
3 years of nursing experience required
Degrees, Licensures, Certifications
Current RN licensure in the state of North Carolina required.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.