SUMMARY

Through home and facility visits and community events, the PHN Case Manger instructs individuals and families in health education and disease prevention.  The PHN Case Manager also serves as the lead Diabetes Case Manager overseeing three other diabetes case managers.  The PHN Case Manager participates in all diabetes related activities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following.  Other duties may be assigned.

1. Conducts home visits to appropriate enrolled IHC patients to determine patient needs and provides Public Health Nursing services. Instructs family in care and rehabilitation of patient and in the maintenance of health and prevention of disease for individuals, family members and the community.
2. Develops, plans and implements a coordinated patient - centered care plan for individuals and families including the establishment of priority health needs and evaluation of care. Instructs individuals, families and caregivers to recognize early signs of disease and deviations from normal health and how to initiate appropriate action.  
3. Serves as the Diabetes Management (DM) Team Lead Case Manager. Manages the productivity and performance of other DM Team members (Registered Dietitian, Physical Activity Specialist, Public Health Representative). Responsible for meeting grant objectives of the SDPI (Special Diabetes Program for Indians) grant.
4. Attends appropriate internal and external partnership meetings on behalf of the Public Health Programs Department, as assigned.
5. Participates in community health screenings by performing screening tests as authorized and interprets findings to individuals and/or families. Assists participants in identifying goals and activities that will lead to improved health outcome.
6. As a Diabetes Team member, participates in all aspects of the Diabetes program and other programs. Activities include Continuous Quality Improvement (CQI), Diabetes Case Management, Intense Case Management, Interdepartmental Collaboratives, and other associated committees and staff meetings.
7. Submits all patient documentation according to IHC Policies and Procedures within the appropriate timeframe.
8. Interprets social and physical factors in the environment that affect the patient’s care. Recognizes attitudes and cultural patterns related to health and researches culturally appropriate informational and educational materials, guides and brochures.
9. Participates in educational activities including Quarterly IHC staff and departmental meetings, mandatory IHC training and continuing education.
10. Assists in the design and implementation of field investigations and research projects as assigned.
11. Participates in Peer Review.