Public Health Nurse II Care Manager for At-Risk Children & High-Risk Pregnancy – (Health)  

DEPARTMENT: Health

SALARY: Grade 66                                           Starting Salary:  $24.7672 Hourly/ $51,515.88 Annually

OPENING DATE:  November 6, 2023                                Closing Date:   OPEN UNTIL FILLED

GENERAL DESCRIPTION OF DUTIES

The primary purpose of this position is to serve as the Care Management for At-Risk Children (CMARC) and Care Management for High-Risk Pregnancy (CMHRP) case manager. This position provides individual and family needs assessments, case management, educational and counseling intervention and community referrals for high-risk children and families. This work includes families with complex economic, social and medical issues such as child abuse and neglect, parental mental illness, parental substance abuse, HIV infection and homelessness. This employee serves as a resource and liaison to other medical providers and agencies. In addition, this position will provide and ensure coordination of services between Department of Public Health Child Youth and Women’s Health (DPH) and Care Management programs through the Health Department. A high level of skill is required to provide case management and determine the appropriate interventions. This employee must stay current on case management, assessment and referral, supportive counseling, intervention, psycho-social therapy and treatment planning.

SPECIFIC DUTIES AND RESPONSIBILITIES

EXAMPLES OF ESSENTIAL FUNCTIONS

This list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. It is not necessarily descriptive of any one position in the class. The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position.

45%        Care Management for High-Risk Pregnancy (CMHRP)

• Refer potentially Medicaid-eligible pregnant women to prenatal care and Medicaid eligibility determination.
• Make timely attempts, following standards outlined in the CMHRP Standardized Plan to contact patient to engage the patient in care management services.
• Develop and utilize motivational interviewing techniques when attempting to engage patient and on an ongoing basis.
• Contact patients identified as having a priority risk factor through claims data (Emergency Department utilization, ante partum hospitalization, utilization of Labor & Delivery triage unit) for referral to prenatal care and assess for care management need.
• Review and enter into Virtual Health, Pregnancy Risk Screening Forms received from Pregnancy Medical Homes (PMH) for women eligible for Medicaid within seven calendar days of receipt of risk screening forms.
• Utilize risk screening data and provider referrals to develop strategies to meet the needs of those patients at highest risk for poor pregnancy outcome.
• Accept pregnancy care management referrals from non-PMH prenatal care providers, community referral sources, (such as WIC and DSS), and patient self-referral, and provide appropriate assessment and follow up to those patients based on the level of need.
• Conduct a prompt and thorough assessment by review of claims history and medical record, patient interview, case review with prenatal care provider and other methods, on all patients who have a Maternal Infant Impact Score (MIIS) over 200 and all patients directly referred for care management to determine level of care management support needs.
• Utilize assessment findings to determine level of need for care management support. Document assessment findings in Virtual Health.
• Assessment documentation must be current throughout the period of time the care manager is working with patient and should be continually updated as new information is obtained.
• Assign case statues as outlined according to program guidelines, based on level of patient need.  
• Provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging patients and meeting their needs, including telephone outreach, practice encounters, home visits, and interventions needed to achieve care plan goals.
• Collaborate with out of county PMHs and CMHRP teams to facilitate cross county partnerships to ensure coordination of care and appropriate Pregnancy Care Management assessment and services for all patients in the priority population.
• Provide care management services based upon level of need as determined through ongoing assessment of the patient.
• Develop patient-centered care plans including appropriate goals, interventions and tasks based on CMHRP guidance, CMHRP standardized plan, CMHRP Pathways, Virtual Health Step-by-Step Documentation Guide for CMHRP.
• Maintain regular collaboration and communication with the prenatal care provider and other clinical providers. Document interactions with all care providers in Virtual Health.
• Identify community resources available to meet the specific needs of the population.
• Refer identified population to childbirth education, WIC, oral health, behavioral health or other needed services reimbursed by Medicaid.
• Refer identified population to community resources including: lactation, parenting, and other supportive services and classes as available in the community.
• Establish a cooperative working relationship and mutually-agreeable methods of patient-specific and other ongoing communication with each PMH.
• Establish effective communication strategies with PMH providers and other key contacts within the practice for each PMH within the county or serving residents of the county.
• Assigned care manager participants in relevant PMH meetings addressing care of patients in the target population.  
• Assess and follow-up on compliance with prenatal care plan and other needed clinical services.
• Ensure changes in status and compliance with care are communicated to the PMH and other appropriate providers.
• Provide education about the importance a postpartum visit. Assist with the scheduling of postpartum visits. Document completed postpartum visits in Virtual Health.
• Support 17P treatment through regular outreach and education to patients on 17P treatment and assist patients in arranging to receive 17P injections in accordance with best practices. Complete the 17P assessment in Virtual Health on a weekly basis.
• Arrange transition from the PMH to a primary care medical home for patients who continue to remain and/or become eligible for Medicaid beyond the postpartum period.
• Maintain regular collaboration and communication with the prenatal care provider and other clinical providers. Document interaction with all care providers in Virtual Health.
• Communicate with Supervisor regarding challenges in collaboration with PMH and non-PMH prenatal care providers.
• Pregnancy care managers shall attend pregnancy care management training offered by the Division of Public Health and /or appropriate entities including webinars and new hire orientation. 
• Pregnancy care managers will attend continuing education sessions coordinated by the Division of Public Health and/or other appropriate entities including program meetings, regional trainings and state wide conferences.
• Pregnancy care managers shall pursue ongoing continuing education opportunities to stay current in evidence–based care management of pregnant and postpartum women at risk for poor birth outcomes. 

45%        Care Management for At-Risk Children (CMARC)

• Responsible to educate patients, medical homes and community organizations on the benefits of the program.
• Contact patients identified as having a priority risk factor through claims data analysis or through the CMARC Referral Form.
• Identify community resources available to meet the specific needs of the population (resource manual).
• Uses data summaries and reports created by NCCCN, Inc. to identify those individuals at greatest risk.
• Utilize the CMARC Referral Form, provider referrals, and children identified through claims data analysis as high cost/high users of services to develop strategies to meet the needs of those children at highest risk for poor outcomes.
• Utilize information entered into Virtual Health, Case Management Information System, such as care plans and assessments and to identify children needing additional interventions.
• Complete and enter into Virtual Health assessments and care plans on all children receiving care coordination.
• Includes the following elements in the assessment:  family status and home environment; medical/behavioral/dental health status; social supports; financial needs; family demands, relationships, and functioning (Life Skills Progression); cultural beliefs and values; strengths/assets of child, family caregivers; and current goals for the child and family.
• Care plans will include goals and expected outcomes.
• Uses risk stratification to determine the services needed.
• Document family progress using the Life Skills Progression instrument.
• Establish processes to support the case coordination of those in the identified population, based upon risk stratification guidelines.
• Provide care coordination services in accordance with the care plan and service pathways utilizing those interventions that are most effective in engaging patients and meeting their needs, including telephone outreach, practice encounters, home visits, and/or other interventions needed to achieve care plan goals.
• Provide care coordination services based upon level of need as determined through the assessment and care planning process.
• Develop patient-centered care plans and document all activities within Virtual Health.
• Identify local community resources available to meet the specific needs of the population.
• Refer identified population to relevant education, oral health, behavioral health or other needed services reimbursed by Medicaid.
• Refer target high risk population to relevant community resources.
• Refer clients to evidence-based parenting programs and other services as appropriate.
• Work with medical homes to assure smooth transitions among and across care settings as needed (e.g. hospital to community) and to develop action oriented care plans as appropriate (including self-management skill building).
• Assess and follow-up on compliance with needed clinical services and developmental screenings.
• Ensure changes in status and compliance with care are communicated to the medical home/PCP and other appropriate providers.
• Provide education about the importance of and assistance with the scheduling of PCP visits and having a medical home.
• Review and monitor reports created for the CMARC program to determine individuals at greatest risk and opportunities for quality improvement.
• Communicate with local network regarding challenges with cooperation and collaboration with PCP and non-PCP related services.
• Attend CMARC and Virtual Health trainings offered by the Division of Public Health and NCCCN, Inc.

5%          Clinic

• Participates in direct patient care of clients receiving services in the Health Department clinic including adult health services, child health services, STD services, immunizations, communicable diseases and tuberculosis control.
• Assesses client’s needs in General Clinic.
• Maintains knowledge of immunizations, physical assessment, TB skin testing and treatment, STD treatments and communicable disease.
• Provides and documents appropriately child health limited history.
• Obtains patient history and work-up of Child Health patient for FNP/MD.
• Maintains knowledge of HIV control measures to prevent spread of HIV within the community.
• Documents in EMR system.

MARGINAL FUNCTIONS

While the following tasks are necessary for the work of the unit, they are not an essential part of the purpose of this

position and may also be performed by other unit members.

5%          Other duties

• Serves as a team member during outreach projects such as flu vaccine season, health fairs, etc.
• Serves as team member during disease outbreaks.
• Serves as team member during disasters for staffing of emergency shelters.
• Other duties as directed by supervisor

MINIMUM TRAINING AND EXPERIENCE

• Graduation form a four year-college or university with BS Degree in Nursing which includes a Public Health Nursing rotation; or
• Graduation from an accredited school of processional nursing and one year of professional nursing experience; or
• An equivalent combination of education and experience.

SPECIAL REQUIREMENTS

• Must be or become certified in basic CPR life support
• Valid, current NC driver’s license
• Reliable means of transportation
• Introductions to Principles and Practices of Public Health Nursing