POSITION SUMMARY:   The HIV Nurse Clinical Care Coordinator is responsible for supporting the patient’s retention in HIV primary care by providing one-on-one medical care coordination and treatment education to adults, children, and youth regarding their HIV treatment regimens.

MISSION PERFORMANCE STANDARDS

Mission Statement:  “To offer comprehensive health and wellness services to the community, to advocate empowerment, to safeguard the rights and dignity of individuals, and to provide for an enlightened public.”

Diligence is required in order to assure continuous achievement of our mission.  Performance standards are achieved when an employee:

• Maintains a high level of professionalism and keep confidential matters confidential.
• Treats everyone (clients, staff, volunteers, board members, etc.) with respect.
• Offers assistance to co-workers whenever needed.
• Demonstrates initiative by identifying problems and actively participates on their resolution.
• Asks for assistance when learning new tasks or unsure of self.
• Takes necessary measures to properly use and maintain supplies and equipment in order to avoid unnecessary expenses.
• Respects the rights of others to a quiet workplace.

QUALITY & COMPLIANCE PERFORMANCE STANDARDS

• This position requires cooperation with the Agency’s Quality Improvement Program.  This includes actively participating in all required trainings, and assisting in creating a culture of quality improvement at the Agency.  Cooperation with the quality program will be an element considered as part of all performance evaluations. 
• This position requires cooperation with the Agency’s Compliance Program.  This includes immediately reporting any concerns, actively participating in all required trainings, following HIPAA regulations, and assisting in creating a culture of compliance at the Agency.  This also includes compliance with the written standards of the Compliance Program, and all applicable federal and state laws.  Cooperation with the compliance program will be an element considered as part of all performance evaluations. 
• Failure to comply with the Agency’s Compliance Program, which may include the failure to report any conduct or event that potentially violates any laws or the Agency’s written compliance standards, will be met by the enforcement of disciplinary action, up to and including possible termination. 

ESSENTIAL PERFORMANCE STANDARDS

• Link and retain patient in HIV primary care and/or prenatal care. 
• Is present during regularly scheduled clinics for assigned patients and/or clinicians.
• Through case conferences and individual consultation collaborate with HIV primary care clinic staff, clinical trials units, and other medical care providers to ensure that HIV-exposed infants, HIV-infected adults, children, and adolescents are successfully retained in care.
• Coordinates and follows up on referrals for specialty care.
• Collect and record biologic, medical appointment compliance and other health outcome indicators for each assigned patient.
• Contacts patient weekly to assure medication adherence, with a goal of 95% adherence.
• Assures that 95% of assigned patients are retained in medical care as measured by at least 2 biologic indicators within a 12 month period.
• Monitors assigned patients’ adherence with their scheduled HIV medical appointments.
• Monitors patients’ lab work and clinical indicators for abnormal values and consults with clinicians as needed.
• Assess client’s ability to successfully comply with the prescribed treatment regimen.
• Provide and educate patients to manage the use of adherence aids such as pill boxes, timers, health trackers/medication charts. 
• Assist and/or fill pill boxes, as needed.
• Provide education to HIV-infected adults, children and adolescents in individual or group settings regarding the pathophysiology of HIV disease.
• Coordinate patient’s adherence and treatment education with social and medical providers.
• Educate patients on practical strategies to remain compliant with medications and to manage side effects.
• Develop with patient and clinical provider a comprehensive plan of care.  The plan should include specific goals, objectives, and actions.
• Link and/or refer patient to services that remove barriers to retention in medical care.  These services include, but are not limited to, transportation assistance, housing referrals, substance abuse/mental health referrals, or emergency assistance.  Follows up on referrals.
• Identify and/or develop appropriate and culturally-sensitive educational material with an emphasis on treatment education and adherence.
• Attend clinical team meetings to staff patient needs.
• Provide feedback and update social and medical providers to assist patients in removing barriers to treatment adherence.
• Conduct home visits with patients, as needed.
• As needed, conduct case finding on patients who are hard-to-reach or lost to follow up to educate and encourage return to primary care.
• Document activities through recording of contacts in program database and monthly progress notes.
• Provides information regarding HIV to the affected community, including family members.
• Works in a collaborative fashion with other FACES team members (mental health, non-medical case management, peer support, ancillary services) to assure that the patient’s needs are addressed.
• Monitors, evaluates and revises interventions as appropriate.
• Utilizes current epidemiological data to describe the epidemic.
• Provides educational presentations utilizing a variety of interactive educational techniques.
• Implements evaluation tools to measure the efficacy of activities.
• Insure active coordination of services with appropriate follow-up.
• Assists in the submission of reports and abstracts as needed.
• Perform literature searches and/or other types of research regarding current health education techniques and prevention methodologies.
• Monitors and reassess patients’ needs, risk and progress.
• Receives direction and supervision from Supervisor regarding patient-specific and organizational issues.
• Participates in activities that relate to HIV secondary prevention, as directed by the Supervisor.
• Participates in staff meetings, supervisory meetings and other meetings as directed by the Supervisor.
• Prepares contact information reports and submit by the fifth day of every month.
• Identifies and participates in continuing education opportunities regarding HIV prevention.
• Maintain a current license with appropriate licensing board in Louisiana.
• Other duties as assigned

POSITION REQUIREMENTS

Education, Work Experience, Knowledge & Skills

• Registered Nurse degree or certificate.   
• One year of HIV-related experience preferred. Ability to counsel, educate and adapt to culturally diverse populations. 
• Excellent verbal and written skills, ability to provide patient centered counseling and education, work with people from diverse backgrounds, and excellent working knowledge of HIV in women, children, and adolescents.

• Necessary technical skills to use Agency’s electronic health record, incident reporting system, email, and other information systems.

WORK CONDITIONS

• May be exposed to infections and contagious diseases, subject to varying and unpredictable situations, travel and home visits, as required.
• Position requires light physical effort, frequent prolonged standing/walking, may occasionally require to lift supplies/equipment, and occasional reaching, stooping, bending, kneeling and crouching.

RESTRICTIONS

• Must adhere to all personnel practices specified in the Employee Handbook and Operating Procedures.