<p>Our Culture: Why work with us?</p> <p>Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.</p> <p>Who We Are:</p> <p>Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.</p> <p>OCHS now cares for more than 20,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it, and validating that staff are working at the top of their licensures, are foundations of this model.</p> <p>Primary Purpose of Position:</p> <p>The Team-Based Care Registered Nurse (RN) is an integral member of the team-based care model, working in close collaboration with providers, medical assistants, behavioral health specialists, and other care team members to deliver high-quality, patient-centered care. The RN supports chronic and acute care management, patient education, preventive care, and population health initiatives in alignment with clinical and organizational priorities.</p> <p>Essential Functions:</p> <p>Direct Patient Care & Clinical Support</p> <ul> <li>Conduct nurse visits including blood pressure checks, wound care, injections, allergy shots, INR checks per standing orders, vaccine administration per standing orders or provider direction, and other visits per protocol. </li><li>Perform triage using clinical protocols, assess patient needs, and coordinate same-day care when necessary. </li><li>Exhibit high level of clinical acumen and decision making to assist in the overall care of patients' acute and chronic needs as part of a highly functioning clinical team. </li><li>Provide medication education and reinforce treatment plans for chronic disease management (e.g., diabetes, hypertension, asthma). </li><li>Perform medication refills per standing protocols. </li><li>Assist with post-hospital discharge follow-up and care transitions. </li><li>Conduct routine patient examinations and assessments according to scope of practice based on licensure and OCHS protocols. </li><li>Provide the best patient experience possible; address patient's concern and questions, explain procedures, testing, and diagnosis thoroughly. </li><li>Educate patient in the proper use of medical equipment, prescribed regimens and other nursing care regimens. </li><li>Refer patient to outside sources, programs, or support groups, for additional education or referrals. </li><li>Other related duties and projects, as required or assigned in order to ensure the needs of the Health Center and its patients are met. </li><li>Other related duties and projects as assigned. </li></ul> <p>Care Coordination & Panel Management</p> <ul> <li>Collaborate with providers and care team members to support panel management and ensure timely follow-up on labs, referrals, and preventive services. </li><li>Participate in pre-visit planning with a focus on leveraging standing orders and written protocols to ensure patients are staying up to date on care gap and chronic disease management. </li><li>Review dashboards and care gap reports to outreach to patients and schedule necessary visits. </li><li>Participate in team-based huddles, case conferences, and interdisciplinary care planning. </li></ul> <p>Team-Based Care & Quality Improvement</p> <ul> <li>Work collaboratively within the care team to ensure a seamless patient experience. </li><li>Contribute to quality improvement projects and help implement population health strategies. </li><li>Support coordination of specialty care, social services, and community-based resources. </li></ul> <p>Documentation & Compliance</p> <ul> <li>Maintain patient records with accurate and timely documentation in the Electronic Medical Record (EMR) in accordance with OCHS policies. </li><li>Ensure compliance with infection control standards, medication safety, and clinical protocols. </li><li>Maintain patient privacy and confidentiality of information at all times in accordance with OCHS policies and HIPAA. </li></ul>