Community Care Nurse, Comprehensive Care Program

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Martin’s Point Health Care is partnering with Health Quality Partners to deliver advanced, community-based preventive care and care management interventions for chronically ill older adults. The HQP model of care focuses on the following:
• Management/prevention of the onset or complications from common chronic diseases – heart failure, coronary artery disease, chronic lung disease, depression, and diabetes
• Avoiding complications and preventing hospitalizations associated with chronic conditions and aging
• Promoting safety and independence and optimizing physical and social functioning
• Assisting with and facilitate long term advanced care planning

The Community Care Nurse provides comprehensive, person-centered, longitudinal community based advanced preventive care and care management (CM) interventions for participants and families enrolled in the Comprehensive Care Program. Effectively engages, assesses, monitors, educates, coordinates, and provides interventions for participants and families to improve the quality of care and participant health outcomes. This role reduces unnecessary health care utilization. Collaborates with physicians, hospitals, skilled nursing facilities, home health providers and community services to advocate for participant-centered goals and needs, to promote better health, and to prevent unnecessary hospital utilization.

  • Company: Martin’s Point Health Care (www.martinspoint.org) in collaboration with Health Quality Partners (www.hqp.org)

    Locations: Seeking 3 positions to serve the Greater Portland area

    Education/Experience:

    • Bachelor or Master of Science in Nursing preferred
    • 10 years of current clinical experience, ideally in one or more of the following areas or specialty practice: medical-surgical, home care, hospice, community health, rehabilitation, long term care, cardiovascular, diabetes, and or pulmonary diseases, oncology and geriatrics.
    • Knowledge of Scope of Nursing Practice in states where licensed

    Required License(s) and/or Certification(s):

    • Unrestricted state licensed registered nurse license required: BSRN or MSRN preferred
    • Valid unrestricted driver’s license