Community Health Nurse (Community Programs)

JHSON seeks a motivated, energetic, and caring RN to serve as a Community Health Nurse as part of an interdisciplinary care team for the Neighborhood Nursing Initiative in Somerset County. Working within the interdisciplinary team, the RN will be responsible for day-to-day implementation of Neighborhood Nursing protocols including initial and follow-up home- and community-based encounters. The RN will receive initial program training and ongoing supervision and will use motivational interviewing techniques to foster a trusting alliance with participants, local stakeholders, and the Somerset County community more broadly. Candidates who are native to or have experience working within Somerset County are highly encouraged to apply. The Johns Hopkins School of Nursing (JHSON) Neighborhood Nursing Initiative (https://neighborhoodnursing.org) actively promotes primary and secondary prevention services through the Neighborhood Nursing team's capacity to provide health assessments and screenings, vaccinations, health education, and care coordination in the community setting. A Registered Nurse (RN) is paired with a Community Health Worker (CHW) and together they deliver comprehensive health and social care directly in people’s homes and community hubs, such as libraries, senior centers, faith-based organizations, and other community sites in Somerset County, Maryland. Specific Duties & Responsibilities Case Management & Clinical Care * Deliver the nursing component of Neighborhood Nursing. * Meet with individuals and families in a variety of community settings including homes, community centers, libraries, and other hub sites across Somerset County. * Provide participant-centered services using a trauma-informed approach. * Effectively use motivational interviewing techniques to engage and coordinate care/services for participants. * Conduct semi-structured clinical interviews to identify and prioritize goals relating to physical, mental, and social well-being using a strength-based framework. * Conduct comprehensive physical health assessments and social determinants of health (SDOH) screenings; initiate appropriate referrals with follow-up to ensure a closed-loop process. * Prioritize acute (urgent) and primary/secondary prevention health and social needs. * Engage participants in problem-solving to identify behavioral and environmental contributors that impact their health (physical, mental, and social). * Co-create action plan based on participant-identified goals. * Provide Point of Care (POC) testing (e.g., blood pressure, blood glucose), vaccinations, health education, and other activities in group and individual settings. * Link and help enroll participants into community resources including health insurance, primary care, specialty care, behavioral health, housing, transportation, food support, and utility support. Outreach & Community Engagement * Initiate and assist in developing strong community relationships in Somerset County; * Attend community meetings and other activities that cultivate trust. * Support with program expansion and hub creation in Somerset * Develop and provide health education and training materials for participants and community members. * Participate in local/state meetings and conferences, maintaining and seeking out partnerships with governmental and non-governmental agencies engaged in community health. * Must have reliable transportation to travel to participant homes and community sites in Somerset County. Administration & Documentation * Collaborate, communicate, and coordinate follow-up care with the Neighborhood Nursing Center. * Assist the Neighborhood Nursing Center in assessing and evaluating the program. * Create and document participant treatment plans, interventions and recommendations, screening results, and health risk assessments. * Document and record outcomes of referrals and appointments. * Use the Neighborhood Nursing data management...