The incumbent is responsible to direct the Diabetes Education and Clinical Nutrition Program at Sacred Peaks Health Center. This entails the following: development and implementation of program goals and objectives with SPHC Medical Director, SPHC Director of Ambulatory Care Services, and TCRHCC Director of Diabetes Education and Clinical Nutrition; planning and implementation of the SPHC diabetes self-management education (DSME) program; evaluation of the DSME program outcomes to direct continuous quality improvement efforts; maintenance of the diabetes registry; completion of the annual Indian Health Service diabetes audit; and consulting on nutrition care to multiple departments involved in direct patient care. The incumbent provides case management services for a sub-population of patients with diabetes, e.g. newly-diagnosed, patients who are pregnant, diabetes in youth, uncontrolled T2DM, etc. Provides direct outpatient medical nutrition therapy to patients with and without diabetes, nutrition/diabetes case management services, and diabetes self-management training in both group and individual settings. Incumbent completes annual foot and diabetic eye screening, glucometer, and continuous glucose monitoring education. Incumbent participates in weekend/holiday rotating on-call schedule to provide medical nutrition therapy for TCRHCC inpatients, both with and without diabetes. Incumbent may also be called upon to provide MNT and DSME services at TCRHCC during the week as needed. This position is a Monday through Friday, 8 am to 5 pm position.
- Provides outpatient medical nutrition therapy and diabetes self-management education.
- Performs individual patient needs assessment to evaluate intervention priorities. Assesses patient needs, medical condition, lab values, nutrition and weight status, self-management abilities, psychosocial concerns, learning factors, mental and emotional health status, access to health care resources, and glycemic control. Provides appropriate level and frequency of care for patients and their families as identified in the individual assessment.
- As part of the health care team, identifies realistic and appropriate interventions and goals based on needs assessment. Supports the patient and health care team in completing the intervention and meeting goals.
- Independently assures planning, development, implementation, and evaluation of the SPHC Diabetes Education and Clinical Nutrition program, such as screening protocols, nutrition/diabetes policy and procedure, marketing, and performance improvement activities.
- Development and carries out SDPI grant objectives, activities, and budgets as it relates to SPHC diabetes treatment and prevention. Participates in the development of the TCRHCC Diabetes Education and Clinical Nutrition budgets as it relates to SPHC.
- Leads in the development of diverse interdisciplinary SPHC programs related to diabetes and obesity prevention and treatment among pediatric and adult patients.
- Leads diabetes self-management education in both individual and group settings utilizing the IHS “Balancing Your Life with Diabetes”, Beautiful Beginnings, and American Association of Diabetes Educators curricula.
- Maintains a registry of patients with diabetes through the Electronic Health Record or another electronic system.
- Tracks and reports productivity through patient contacts and outcomes on a daily, weekly, monthly, and quarterly basis.
- Applies theoretical approaches such as motivational interviewing, stages of change theory, and empowerment theory to facilitate behavior change. Effectively communicates with patients and families in a culturally sensitive manner.
- Develops and implements tele-nutrition programs for various populations, including the Adolescent Medicine team to provide MNT to teens in school-based clinics, and other Indian Health Services sites, providing nutrition consultant services to a variety of sites and disciplines.
- Provides consultant services to pediatricians on infant nutrition, pediatric nutrition, adolescent nutrition, and specialty pediatric care program development.
- Recommends adjustment of treatment plan utilizing patient blood glucose monitoring data to optimize glycemic control. If adjustments in medications are indicated, consultation with the primary care provider or attending physician is done; if the primary care provider or attending physician is not available, consultation will be done with the physician on call from the same service.
- Serves as an essential member of the primary care team for patients with nutrition, weight, and/or physical activity-related conditions as part of the Patient-Centered Medical Home (PCMH) initiative. Serves as a liaison between the individual and primary care provider to ensure the highest quality of coordinated care.
- Utilizes a case management model to follow sub-populations of diabetes patients. Ensures patients receive recommended services and appropriate follow-up according the to Diabetes Standards of Care.
- Provides consultation to medical, nursing, and other staff throughout SPHC to provide coordinated, team-based, high-quality diabetes and nutrition care in all settings.
- Attends and participates in Clinical Services team meetings, SPHC staff meetings, TCRHCC Diabetes Advisory Committee, and other committee efforts as appropriate.
- Serves as a clinical expert and resource on diabetes, nutrition, and pediatric nutrition, maternal health and wellness to SPHC. Initiates and develops in-service training to staff to keep staff updated on issues pertaining to pediatrics, maternal, diabetes, and nutrition.
- Provides inpatient medical nutrition therapy to patients with and without diabetes on a rotating weekend/holiday on-call schedule.
- Prepares patient education materials as needed, seeking approval for use of new or updated materials through the Patient Education Materials Committee.
- Maintains confidentiality regarding administrative and patient related care.
- Maintains current licensure, job-related competencies, and knowledge of evidence-based guidelines through active participation in continuing education, independent study, seminars, in-services, and dialogue with colleagues.
- Develops and assists with Performance Improvement initiatives.
- Operates, monitors, and maintains patient care equipment.
- Employs the Association of Diabetes Care & Education Specialist AADE7 Self-Care Behaviors framework.
- Assists Community Connectors by providing distribution of food, water and other necessary essentials to community members who are in isolation or quarantine.
- Assists the Contact Tracing team by performing contact tracing activities for patients testing positive for Covid-19, and conducting negative results calling.
- Assists the Screener/Greeter at various entry points to ensure appropriate screening for all patients and visitors entering the TCRHCC campus.
- Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly (see CDC website for most current updates).
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer satisfaction.
- Performs other duties as assigned.
MENTAL & PHYSICAL JOB REQUIREMENT
The physical and mental demands described here are representative of those that must be met by an individual to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to sit at a desk for long periods of time, occasionally stand and walk, write legibly and use a computer terminal. Must be able to occasionally lift, push and pull up to 24lbs. Must be able to use a keyboard. Sensory requirements are ability to continuously hear normal speech, overhead pages and use a telephone, frequent ability for far vision and near vision and occasional color vision. Must be able to hear and talk over the telephone and in person with others.
Must be able to prioritize and use good judgment. Must be able to coordinate a variety of issues while being frequently interrupted. Must be able to assess data such as lab values and weights. Must have ability to frequently concentrate, handle high degree of flexibility, demonstrate high degree of patience, occasionally cope with high levels of stress, make decisions under high pressure, cope with anger/fear/hostility of others in a calm way, handle multiple priorities in stressful situation, and adapt to shift work. Must also accept a flexible schedule to meet unit needs.
May occasionally be exposed to infectious diseases, chemical agents, dust, fumes, and gases.