RN (Wellness Nurse) -Vista Towers (Koreatown, 90005)

Creative Housing & Services
Los Angeles, CA, US
Sep 14, 2017
Oct 06, 2017
Contract Type
Job Description

RN needed to work with seniors in a vibrant affordable housing community located in the Korea Town area of Los Angeles. This 3- year HUD funded grant program is designed to help residents of the community navigate the health system, and be directed to available resources for services. The RN will assess needs and provide guidance and assistance to maintain resident health and wellness while living independently in their own home. The successful candidate will not provide bedside care, but will collaborate with the community based team and outside health and service providers in an effort to keep the resident healthy, happy and in their own home as long as possible. Previous work with seniors, case management experience and ability to speak Korean a plus.


The Wellness Nurse (WN) is a three-year, grant-funded position under the U.S. Department of Housing & Urban Developments Supportive Services Demonstration (SSD). Any funding for the WN position is subject to the availability of funds after the demonstration ends, with no expectation that there will be a continuation of funds.

The WN provides residents participating in the supportive services demonstration with health education and coaching to facilitate improved self-care management, individual medication management support, develops and/or coordinates wellness and prevention activities, and assists with wellness and service coordination and health services access to help optimize resident health and well-being. The WN works with residents in both one-on-one and group settings. The WN works in concert with the resident and their family members, if appropriate, the Enhanced Service Coordinator (ESC), and community partners to help residents address their needs, achieve their goals, and support their ability to safely age in place.

The WN utilizes the quantitative and qualitative data obtained from person centered interviews and a comprehensive standardized health and wellness assessment to actively support residents self -selected wellness goals. The WN will collect vitals such as blood pressures during the initial assessment and will use their judgment regarding tracking of vitals to assess resident achievement of health goals.


  • Assist the ESC in outreach and education activities to encourage resident participation and enrollment in the supportive services demonstration.

  • Collaborate with the ESC, with each role conducting designated parts, to complete an initial and periodic health and wellness assessment that gathers information about the residents physical, mental, functional, and social status.

  • Assist the ESC in developing individual-level and community-wide healthy aging plans to address identified interests and needs. Plans are guided by information from the individual assessments, summary reports of aggregate needs pulled from the data platform, personal observations, and input from partners.

  • Implement components in the individual and community healthy aging plans identified to be the responsibility of the WN.

  • In collaboration with the ESC, monitor the ongoing delivery and receipt of services, and periodically assess residents for new assistance and care needs in response to changing circumstances.

  • Engage and motivate residents to be active participants in improving/maintaining their health and well-being.

  • Assist residents with medication self-management through activities such as helping residents understand medications, reconciling medications, assisting with establishing a system for remembering and taking medications. Medication reconciliation refers to creating the most complete and accurate list possible of a residents medications. The WN should not give recommendations of any medication changes, but should assist the resident in alerting their physician to any potential concerns that may have been identified.

  • Monitor vital signs.

  • Provide health education and wellness group activities, informed by needs identified in resident interviews and assessments.

  • Support and coach residents to improve management of chronic conditions and adopt healthy behavior changes.

  • Develop relationships with and communicate with primary care practices and other health entities to assist residents with relaying health information and coordinating health services.

  • In collaboration with the ESC, monitor discharge plans to help ensure timely follow-up and coordination of care for residents discharged from the emergency department, hospital, skilled nursing facility, or home health care.

  • Establish and maintain communication channels with the ESC, community partners, and property management staff to appropriately share information concerning residents and identify ways in which resident needs can be addressed. Ensure all sharing of resident information is done only with resident permission and respecting privacy and fair housing guidelines.

  • Maintain all necessary resident and program data in the electronic data platform, including information from the person-centered interview and health and wellness assessment, interactions with residents, resident participation in programs, and sentinel resident events (e.g. falls, ED visits, etc.).

  • Maintain and share all personal resident information in accordance with applicable privacy and confidentiality requirements.

  • Collaborate with the SSD Implementation and Evaluation Teams, including participating in all trainings, to the greatest extent possible; engage in peer-to-peer learning activities; engage in a quality assurance process; and participate in interviews, surveys or other evaluation activities.

Prohibited Functions:

  • Procure, dispense, and administer any medication/controlled substance.

  • Provide direct clinical care.

  • Direct or supervise care delivered by other healthcare personnel or providers to residents.


  1. Graduate of an accredited nursing program with a current unrestricted license as a registered nurse (RN) in state of practice. LPN/LVN may be considered with appropriate skills and experience.
  1. Ability to translate medical jargon into easily understandable lay language and to communicate at appropriate literacy and cognitive levels.

  2. Aptitude in providing education on health and functional conditions commonly experienced by older adults.

  3. Understanding of and sensitivity to the needs of low-income older adults and persons with disabilities.

  4. Ability to self-direct and work independently, but also function well as part of a team.

  5. Ability to multi-task and establish priorities in a sometimes busy and stressful environment.

  6. Ability to establish positive and collaborative relationships with residents, staff and community-based providers.

  7. Basic computer proficiency, including ability to maintain data in an electronic database, communicate via e-mail, use internet, and operate word processing software to create program materials.


  1. Experience in community health nursing, including such practices as conducting wellness and prevention activities, providing health education and coaching, considering community/population needs, and engaging with community service providers.

  2. Experience in working with or providing care to older adults.

  3. Experience conducting assessments that accurately and appropriately identify an individuals physical and mental health and functional needs, and using this information to develop and implement care plans.

  4. Experience using motivational interviewing, active listening, and person-centered care concepts to help encourage individuals to engage in addressing and managing their own health care conditions.

  5. Knowledge of or certification in delivering standardized or evidenced-based health education and prevention programs (e.g. Chronic Disease Self-Management Program).

  6. Cultural competency in working with diverse populations and individuals from different ethnic and racial backgrounds, including working with non-English speaking adults.

  7. Familiarity and understanding of working with individuals with mental health needs.

  8. Knowledge of primary care practice operations.

  9. Strong verbal, written, and interpersonal communication skills

  10. Understanding of using data to monitor and improve program practices and operations.

  11. Bi- or multi-lingual in languages most commonly used by residents at the property.


Attends all mandatory meetings and in-services.

Exhibits clean and neat appearance. Follows dress code standards. May be required to wear a uniform as established by department policy.

Follows all safety precautions, including use of necessary devices or equipment.

Uses highest standards of cleanliness. Adheres to all infection control and Universal precaution guidelines.

May be requested to remain on premises during certain shifts when alternative coverage is not available; On Duty Meal Period agreement will be signed and employee compensated accordingly.

QUALIFICATIONS REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Employees must satisfactorily attain and maintain DOJ Criminal Record Clearance. Pre-employment drug screening and physical required; thereafter, an annual physical will be requested.


Graduate of an accredited nursing program.

Current unrestricted license as a registered nurse (RN) in state of practice.

At least two years of experience in managing or providing care of geriatric persons in elder care setting preferred.

Prefer at least two years of experience conducting Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL) assessments that accurately and appropriately identify the functional limitations of residents.

Demonstrates knowledge of changes associated with aging and principles of growth and development, relevant to the adult and geriatric age groups; Strong interpersonal skills that will allow for successful collaboration and cooperation with Enhanced Service Coordinator, service providers, health care providers and most importantly, elderly residents and their caregivers.

Knowledge of legal liability issues relating to provision of in-home health related services.

Other qualifications as determined necessary by the research design.

LANGUAGE SKILLS: Ability to read, analyze and interpret professional journals, technical procedures, or governmental regulations. Ability to write reports and perform charting. Ability to effectively present information and respond to questions from groups of managers, residents and their families, and the general public.

MATHEMATICAL SKILLS: Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

REASONING ABILITY: Ability to define problems, collect data, establish facts, and draw valid conclusions.

PHYSICAL DEMANDS: The physical demands here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; walk; use hands to handle, or hold objects, use a writing instrument and telephone; speak or listen in person. The employee frequently is required to reach with hands and arms. The employee is occasionally required to sit; assist residents to balance, stoop, kneel, and bend; and smell if conditions are unsanitary.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally exposed to toxic or caustic chemicals such as cleaning supplies and medical preparations. May be exposed to pets and pet dander.

The noise level in the work environment is usually moderate.

Company Description

Creative Housing & Services (CHS) is the specialized affordable housing and property management services branch of the ECS not-for-profit family tree.

In keeping with the longstanding mission and core values of Episcopal Communities & Services, CHS puts its primary focus on the well-being and life-enriching care of older adults. We do this by owning and/or managing affordable residential communities for income- and age-qualified individuals throughout the Greater Los Angeles area.

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