Community Health Nurse/ Case Manager

Full-time - Senior
NE Kingston, WA

Port Gamble S'klallam Tribe

Posted On: Feb-08
Status: Open

The mission of the Port Gamble SKlallam Tribes Community Health Nurse/ Case Manager position is to enhance the health status and quality of life of Tribal Members and other American Indian/Alaskan Native and non-Indian individuals who use the tribes health services. This is completed through the delivery of excellent health education, nursing care and case management services.


The purpose of this nurse position is to provide comprehensive preventive and therapeutic nursing care and nursing triage for the members of the tribal community in the clinic and home care settings. Nurse case management services emphasize preventive and supportivecare for community residents.


This position operates within a strong team environment and under the standards of the Port Gamble SKlallam Tribes Health Services Department.


Duties Include:


  • Provides comprehensive preventive, supportive, and therapeutic nursing care for diabetic & elder clients with complex medical needs in the community setting, home setting and at the SKlallam Health Clinic as needed.
  • Provides intensive case management services to Port Gamble SKlallam clients with diabetes, working closely with their primary care providers.
  • Provides diabetes education and outreach to community members and coordinates case finding and case management services through the SKlallam Health Clinic.
  • Assists with the IHS Diabetes Grant by performing chart reviews and coordinates quality improvement activities related to diabetes (see Grant Administration).
  • Provides education and outreach to community members and coordinates case finding and case management services through the SKlallam Health Clinic.
  • Arranges for medical services for patients/clients functioning under established routines and medical protocols and assists with arranging transportation as needed.
  • Reviews and may order laboratory tests, immunizations, diagnostic procedures and consultation services in conjunction with patients primary care provider, following PGHC care standards and provider standing orders.
  • Provides intensive case management to elders and vulnerable adults with complex medical needs, working closely with their primary care providers.
  • Assesses immunization status of patients and their family members, and makes recommendations for vaccinations.
  • Administers immunizations following the clinics standing orders for adult and childhood vaccinations.
  • Maintains regular contacts of a positive nature with clients, staff, community members, Indian Health Service, Northwest Portland Indian Health Board, DSHS, Health Department, Tribal dentist, local physicians, medical services providers, social service agencies, Extended Care Facilities, PGST Elder Advocate, Senior Lunch Program, Community Health Representatives, and others to accomplish SKlallam Health Services objectives and preserve good public relations.
  • Works closely with the tribes Elder Program Manager and Community Health Representatives in the provision of elder case management services.
  • Orders over the counter medications when in the nurses judgment, they are indicated, in conjunction with patients primary care provider.
  • Administers oral, subcutaneous, intradermal, and parenteral medications with precision and accuracy.
  • Documents consistently all medications given in the health record, noting site, method, amount, time and when appropriate, the patients response to the medication. Prepares medi-sets on a weekly basis for case managed patients as needed and under the review and approval of the patients primary care provider.
  • Performs procedures in the community setting that may be therapeutic and/or helpful to assess the clients immediate health status (e.g. weight, height and abdominal circumference and BMI measurements); vital signs including temperature, pulse and respirations; administering vaccinations, blood pressure monitoring, medication management and/ or administration, blood glucose monitoring.
  • Provide foot assessments and foot and nail care for diabetic and elder patients when requested.
  • Interprets selected laboratory findings and as appropriate, initiates action for necessary care (such as scheduling follow up appointments with health care provider).
  • Notifies patients of lab results/diagnostic procedure results as requested by health care providers.
  • Assists providers in the clinic setting as needed (e.g. completing labwork, starting IVs, completing vital sign assessments etc).
  • Assists with discharge planning and ordering of durable medical goods for patients who are returning home from a hospital or nursing home.
  • Coordinates with the Health Clinic in maintaining adequate clinic medications, supplies and equipment.



  • Provides nursing triage of medical problems during home visits or community activities, ascertaining severity and arranging appropriate services following the Health Clinics nurse triage procedures. Provides after hours triage services when needed.
Case Management Documentation
  • Performs physical assessments, recognizing the range of normal and the manifestations of common abnormalities.
  • Utilizes the SOAP nursing process in assessing and planning for client care. Subjective, Objective, Assessment, Plan and re-evaluates interventions and repeats the SOAP process as necessary.
  • Documents assessments, interventions and nursing care plans in the electronic health record.
  • Completes appropriate referrals to other team members and referral agencies in the community that provides the necessary service.


Health Education:

  • Provides teaching to individuals and families about treatments, medications, nutrition, exercise, immunizations, health maintenance and preventive screening tests.
  • Emphasizes education on resources and services for tribal elders and provides information to community members on all of the services available at the SKlallam Health Center and other resources in our area.
  • Emphasizes education for patients with chronic illnesses such as diabetes and heart disease and may provide education to individuals, families and groups in a variety of settings.
  • Provides chronic disease self-management education.
  • Participates in the coordination and implementation of various cultural and disease prevention activities in the community. These include the annual health fair, diabetes awareness month, client case conferences, wellness conference, canoe journey medical tent and others.
  • Prepares for specialty clinics including community outreach clinics by seeing that necessary supplies and equipment are available and work area is set up to accommodate the particular activity.

Case Management:

  • Promotes continuity of care by relevant health counseling, referrals for follow up care, arranging for appointments and collaborating with other agencies involved in health care.
  • Promotes independence and optimal health by assisting patients with referrals and access to needed community services.
  • For the RN/Community Health Nurse, case management, is provided via clinic, home or community visits to tribal members, and with phone follow-up as needed.
  • Participates as a member of the PGST vulnerable adult team including attending monthly meetings.
  • Work closely with DSHS COPES program case manager to facilitate elders and vulnerable adults receiving needed in home care services

Quality Improvement:

  • Assists in determining conditions, resources and policies essential for the delivery of quality medical and community health nursing services.
  • Develops routine and follows guidelines that will ensure continuity and consistency in the provision of nursing service in the community.
  • Initiates quality improvement activities for improving care to patients.
  • Communicates with PGHC providers and outside medical providers in Kitsap County about individual chronic patient care plans and standards of care.
  • Attends and participates in various community meetings and staff committees whose goals directly or indirectly relate to the SKlallam Community Health program objectives.



  • Education: Graduated from a NLN approved School of Nursing with a B.S.N.
  • Licensing: RN required with WA. State Licensure and Certification, valid WA state Drivers license and proof of insurability. Home Health or Community Health Nursing experience preferred.
  • Clinical Experience: Professional knowledge of, and ability to apply nursing care principles, practices and procedures required to assess needs of wide variety of adult and geriatricmedical and surgical patients as well as knowledge of the normal course of diseases, anticipated complications and indicated therapeutic intervention. Ability to provide individual and family counseling, guidance and health instruction so that they can assume responsibility for their own health status. Knowledge of community health promotion principles and home health nursing skills.Knowledge of pharmaceuticals and immunization administration and their desired effects, side effects and complications of their use. Knowledge and skill in operation of specialized medical equipment, such as glucose monitors, pulse oximeters etc.
  • Personal Computer Skills: Basic personal computer skills are required, as well as the ability to learn word-processing, spreadsheet and other software programs. Experience with electronic health records desired.



  • Crouching: Bending the body downward and forward by bending the knee and spine.
  • Reaching: Extending hands and arms in any direction.
  • Standing: Particularly for extended periods of time.
  • Walking: Moving about on foot to accomplish tasks.
  • Fingering: Picking pinching, typing or otherwise working primarily with fingers rather than with the whole arm or hand as in handling.
  • Grasping: Appling pressure to an object with the fingers and palm.
  • Feeling: Perceiving attributes of objects, such as size, shape, depth, temperature, or texture by touching with the fingertips.
  • Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to workers accurately, loudly or quickly.
  • Hearing: Perceiving the nature of sounds with no less than 40 db loss @ 500Hz, 1,000 Hz and 2,000 Hz with or without correction. Ability to receive detailed information through oral communication, and to make fine discriminations in sound, such as when making fine adjustments on machined parts.
  • Lifting and Moving: exerting up to 50 lbs of force occasionally, and/ or up to 20 lbs of force frequently, and/or up to 20 lbs of force to move objects.
  • Visual Acuity: minimum standard for use of computer and medical equipment where the seeing job is at or within arms reach.
  • Work Conditions/Exposure to Hazards: a variety of physical conditions such as proximity to moving machinery (e.g. centrifuge), electric current, exposure to body fluids, medications, cleaning fluids. Vaccines etc.


Travel Requirements:

  • Local, Statewide and out of state travel may be required.
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