at Cathedral Square in South Burlington, Vermont, United States
Job Description
Position Title: SASH Wellness Nurse
Reports To: SASH Team Leaders
I. Position Summary:
Location: As Assigned
The Wellness Nurse is responsible for provision and/or oversight of wellness care and
coaching for SASH participants in accordance with Vermont's Nurse Practice Act. S/he is
responsible for overseeing the well-being of participants and in coordinating health services
with other members of the SASH Team and other community providers. S/he supports a
philosophy of aging in place consistent with the mission of SASH. The Wellness Nurse will
also work with the SASH Team on developing individual participant Healthy Living Plans as
well as Community Healthy Living Plans.
II. SASH Wellness Nurse Principal Responsibilities by Intervention Category
A. Transitional Care Interventions – The SASH Wellness Nurse performs the following
duties related to the SASH transitional care interventions:
• Communicates closely with SASH team members to help facilitate safe and effective
transitions for SASH participants between off-site care facilities and home;
• As determined by SASH team action planning, and as schedule allows, makes in
person visit with SASH participant shortly after return home. As appropriate, follows
home visit intervention strategies of the evidence –based Care Transitions Intervention
(Coleman et al). including medication management, coaching on importance of
scheduling follow-up medical appointments, and education on identifying early
warning signs of health complications;
• Updates progress notes section of the participant’s Health and Wellness record so that
all SASH team members have current information;
• Communicates to SASH Coordinator(s) the need for daily check-ins, further care
coordination tasks required, delegate any other required duties to the SASH
Coordinator or PCA as appropriate according to delegation policies. (Included in
Tools and Resources Section).
B. Self-Management Education Interventions- The SASH Wellness Nurse plays an
important role, in concert with the SASH Coordinator, in coaching, encouraging and
promoting the importance of self-management of chronic health conditions with SASH
Participants. When meeting with SASH participants for regular wellness visits (one-on
one or in group visits), the Wellness Nurse has the opportunity to educate participants on
self-managing symptoms and problems, the importance of participation in activities that
promote good health and decrease symptoms and regular and open communication with
their Physician(s). The SASH Wellness Nurse performs the following duties related to the
self-management education interventions provided through the SASH model:
• Offers regular wellness visits (one-on-one and group wellness programming) for
participants and provides the following services as appropriate and needed for the
participants:
o Preventive wellness care interventions such as blood pressure checks, heart rate
monitoring, weight monitoring, and foot care (if time allows);
o Reviews participant’s medications, updates medication record as necessary,
communicates any discrepancies or concerns regarding medication regiment with
participant and PCP office if deemed necessary;
o Monitor participant’s overall physical and mental status as needed and appropriate,
maintains documentation through the SASH Participant Record and reports any
changes to SASH team, family members and PCP as appropriate;
o Provides information and education on health issues, stressing the importance of
participation in preventative activities, evidence based practices and the active self
management of chronic conditions.
• On an as-needed basis, sets up medication tracking systems with participants and their
family members/caregivers to increase medication compliance;
• On an as needed basis and in collaboration with family members/caregivers pours
medications (on temporary basis) for participants as part of a self-management
medication adherence strategy and delegates medication reminders to SASH
Coordinator and/or PCA (where available) as needed and appropriate.
C. Coordinated Care Interventions- The SASH Wellness Nurse plays a central role in
ensuring coordinated care and services are provided for SASH participants. Due to
regular wellness visits with SASH participants the Wellness Nurse will have current and
reliable information on participants’ health status and self-management skills. The SASH
Wellness Nurse performs the following duties related to SASH coordinated-care
interventions::
• Conducts wellness assessments with SASH participants;
• Assists SASH team in identifying High, Moderate and Low Risk participants using the
Participant Health Risk Criteria as a guide (included in Tools and Resources Module);
• Participates in regular SASH team meetings ensuring close interaction and
coordination between care providers with no duplication of services;
• Provides input to SASH Coordinator on the development of individual Healthy Living
Plan (HLP)drafts with particular attention to moderate and high risk SASH
participants;
• As determined in SASH team meetings, takes lead when appropriate, on targeted HLP
interventions agreed to by participant to meet their wellbeing goals;
• In collaboration with SASH Coordinator, monitors participant’s progress in reaching
their HLP goals and documents any changes to HLP agreed to by participant;
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• On an as-needed basis delegates tasks following the Nurse Delegation Procedure (in
Tools and Resources Module) to the SASH Coordinator and/or Personal Care
Attendant (where available) to help ensure adequate supports are in place for SASH
participants;
• In communities where a PCA is contracted for on-site services, the Wellness Nurse
provides overall support to PCA in collaboration with SASH Coordinator and
contracting agency.
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IV.
Other General Duties:
• Works independently and as part of a team to carry out job duties.
• Communicates in a positive and respectful manner with participants, co-workers,
visitors and family members.
• Communicates schedule with SASH Coordinator and Supervisor in planning leaves or
vacations.
• May fill in for other Wellness Nurses as needed.
SASH & Cathedral Square Professional Standards of Conduct:
• Demonstrates a commitment to the mission and values of SASH and the Cathedral
Square.
• Demonstrates respectful and effective communication with co-workers, participants,
families and vendors.
• Protects the privacy and confidentiality of information related to participants, families,
staff and general organizational operations.
• Follows HIPAA guidelines regarding maintaining client confidentiality.
• Conducts him/herself in a safe manner by adhering to all safety practices, rules and
standards throughout the work day.
• Demonstrates a commitment to quality and proactively seeks to make improvements to
systems and processes.
• Maintains a professional appearance that is appropriate for their position.
• Reports to work on time, completes time card accurately in Evoclock, provides
advance notice for time off, and appropriately manages CTO time.
• Demonstrates a commitment to integrity in work habits and use of SASH resources.
• SASH’s mission and operations require that an employee is prepared to perform duties
as assigned that may be outside their principal responsibilities.
Minimum Qualifications:
The Wellness Nurse must be currently licensed as a Registered Nurse or Licensed
Practical Nurse in the State of Vermont. Must possess at least two years of experience in
a clinical setting, committed to an aging in place philosophy. They must have
demonstrated leadership skills and the ability to exercise sound judgment. They must have
knowledge of standard record keeping procedures (i.e. progress notes, HIPAA guidelines).
Must be able to work independently and part of a team, and possess strong organizational
and time management skills and excellent verbal and written communication skills.
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V. Working Conditions and Physical Demands:
• Work environment requires a participant centered approach to care.
• Employee will be exposed to body fluids, infection, odors, chemicals and cleaning
solutions.
• Employee will be required to care for some residents who may have difficult behavioral
challenges and/or demanding family members and/or guardians.
