Purpose:

Provide person-centered nursing guidance, health coordination, education, and clinical oversight for people supported through AIM’s Self Direction, Independent Living and Housing Initiatives. The RN helps each people identify and manage health-related needs while living independently, primarily through Self Direction. Working in partnership with the person, their circle of support and the Independent Living and Housing Initiative team, the RN promotes informed choice, independence, safety, and successful community living. Responsibilities include nursing assessment, education, medication-related support, development of individualized plans, and in-person or telehealth follow-up based on the person’s needs and preferences.

Qualifications:

• Current / Valid New York State RN License
• At least one year of nursing experience involving community health, care coordination, medical-surgical nursing, home care, developmental disabilities, or another setting relevant to supporting people with complex health needs in the community.
• Demonstrated ability to provide nursing support in a person-directed, community-based model; respect informed choice and dignity of risk; communicate clinical information in accessible language; collaborate with self-hired staff, families, Care Managers, Support Brokers, Fiscal Intermediary staff, and community health care providers; and balance independence with individualized health and safety safeguards.
• Flexibility with schedule to support the needs of the people served
• Valid NYS Drivers’ License, acceptable to Agency insurance standards is preferred.  Maintain valid insurance and provide insurance card if you use your own vehicle.
• Strong organization skills with a keen ability to prioritize and multi-task.  Detail oriented.
• Excellent verbal and written communication skills. 

Reports To: Director of Independent Living and Housing Supports, with clinical supervision and consultation from the Director of Clinical Services or designee.

Person-Directed Practice: The RN/Health Coordinator recognizes that each person directs their own life and services to the greatest extent possible. Nursing recommendations will be explained in accessible language, reflect the person’s goals and preferences, support informed decision-making, and preserve the person’s authority over their home, schedule, providers, and self-hired staff. Information will be shared with family members and other supporters only as authorized by the person or otherwise permitted by law.

Essential Functions:

• Work with each person and their circle of support to address health conditions, medications, functional abilities, communication needs, self-management strengths, needed support, and the person’s health-related goals and preferences. Develop recommendations and plans with the person and their chosen team and provide timely follow-up when needs or circumstances change.
• Support each person’s health through an individualized combination of visits, telehealth contacts, record review, and communication with authorized members of the person’s support team. The frequency and method of follow-up will be based on assessed needs, identified challenges, the person’s preferences, and applicable requirements.
• Evaluate and support the use of assistive technology, remote supports, medication reminders, electronic health tools, accessible communication systems, and other technology that may increase independence, improve access to health information, and reduce reliance on paid support. Collaborate with the person and their team to identify appropriate options, provide education and training, monitor effectiveness, address privacy and safety considerations, and adjust technology supports as the person’s needs and preferences change.
• Provide education, competency-based training, clinical guidance, and ongoing support to self-hired staff and other authorized supporters, as requested by the people you support. Training may address medication administration, delegated nursing services, diabetes care, skin integrity, positioning, mobility equipment, and other person-specific needs.
• Support the person, and authorized members of their team when requested, to schedule, prepare for, attend, and follow up on medical appointments. The level of RN involvement will reflect the person’s preferences, assessed needs, and available natural and paid supports.
• Work with each person to build skills and confidence in managing their health to the greatest extent possible, including understanding health conditions, communicating with health care providers, scheduling appointments, recognizing changes, obtaining refills, organizing medications, and safely self-administering medications when appropriate. Assess current abilities, identify the supports or accommodations needed, provide education and skill-building opportunities in accessible formats, and periodically evaluate progress with the person and their chosen team.
• Communicate and coordinate medical and health information with family members, health care providers, and outside agencies as authorized by the person or otherwise permitted by law. Share only the information necessary to support coordinated care, informed decision-making, and continuity of services.
• Collaborate with the person and their team to develop and maintain individualized health and safety plans, including guidance for changes in condition, urgent and emergency situations, medication concerns, unavailable staff, hospital admission and discharge, and continuity of essential supports. Ensure that self-hired staff and other authorized supporters understand their responsibilities, available resources, and when to contact a health care provider, 911, or another identified emergency resource.
• Provide direct support as requested/required.
• Ensure compliance with all applicable state, federal and agency policies and procedures.

Other duties:

• Participate on committees as assigned/needed.               
• Any and all other related duties as requested by supervisor.