Position Summary: 

The Wellness Nurse is responsible for provision and/or oversight of wellness care and health coaching for SASH participants in accordance with Vermont’s Nurse Practice Act and the SASH Wellness Nurse Core Competencies.  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 health providers.  S/he supports a philosophy of aging in place consistent with the mission of SASH.


SASH Wellness Nurse Principle Responsibilities by Intervention Category 

  1. Foundations of Wellness Nursing – The SASH Wellness Nurse (WN) will possess the core knowledge and preventative health care philosophy that is fundamental to the SASH wellness nursing practice in the domains of –
    • Wellness promotion
    • Illness prevention and health protection
    • Community-based nursing practice
  2. Elements of SASH Wellness Nursing – The SASH WN will possess competencies that focus on nursing activities, interventions, goals, and outcomes that are central to the SASH wellness nursing practice
    • Care Coordination – The SASH WN plays a central role in ensuring coordinated care and services are provided for SASH participants. The SASH WN performs the following duties related to the coordinated care interventions provided through the SASH system:
      • Conducts wellness assessments with SASH participants;
      • Assists SASH team in identifying High, Moderate and Low Risk participants;
      • 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) 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;
      • On an as-needed basis delegates tasks following the Nurse Delegation Procedure to the SASH Coordinator and/or Personal Care Attendant (where available) to help ensure adequate supports are in place for SASH participants;
    • Transitional Care – The SASH WN performs the following duties related to the transitional care interventions provided through the SASH system:
      • Communicates with SASH team members to help facilitate safe and effective transitions for SASH participants between off-site care facilities and home;
      • Implements home visit interventions as deemed necessary and provides in-person home visits with SASH participants after return home, as the SASH WN schedule allows. As appropriate, follows home visit intervention strategies of the evidence–based Care Transitions Intervention (Coleman et al). including planning for self-management of medications, coaching on importance of scheduling follow-up medical appointments, and education on identifying early warning signs of health complications;
      • Updates encounter 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 wellness checks, further care coordination tasks required, and delegates any other required duties to the SASH Coordinator or PCA as appropriate according to delegation policies.
    • Self-Management Education – The SASH WN 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 WN 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 primary care provider(s). The SASH WN 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:
        • Preventive wellness care interventions such as:  blood pressure clinics, evidence-based educational programs, medication review, overall health status, information/education training, and answers questions the SASH participant and their family members may have.
        • 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; collaborates with participant on a plan for self-management of medications;
        • 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;
        • 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.
    • Therapeutic Partnership – The SASH WN possesses the ability to adapt their practice continuously to meet holistic needs of the SASH participant, taking into account individual socioeconomic, cultural, ethnic, and spiritual values and beliefs in order to develop rapport.
  3. Performs other general duties:
    1. Works independently and as part of a team to carry out job duties.
    2. Demonstrates proficiency in basic computer competence and the ability to learn all relevant applications (i.e. electronic health records, care management systems, spreadsheets, and email systems).
    3. Learn how to articulate understanding of how data collected in wellness nursing practice creates SASH clinical outcomes and relevance to the program.
    4. Communicates in a positive and respectful manner with participants, co-workers, visitors and family members.
    5. Communicates schedule with SASH Coordinator and Supervisor in planning leaves or vacations.
    6. May fill in for other Wellness Nurses as needed.

Professional SASH Standards of SASH Wellness Nursing:

  1. Demonstrates a commitment to the mission and values of SASH and the employing agency
  2. Demonstrates respectful and effective communication with co-workers, participants, families and vendors.
  3. Protects the privacy and confidentiality of information related to participants, families, staff and general organizational operations.
  4. Follows HIPAA guidelines regarding maintaining client confidentiality.
  5. Conducts him/herself in a safe manner by adhering to all safety practices, rules and standards throughout the work day.
  6. Demonstrates a commitment to quality and proactively seeks to make improvements to systems and processes.
  7. Maintains a professional appearance that is appropriate for his/her position.
  8. Reports to work on time, provides advance notice for time off, completes timesheets accurately and appropriately manages CTO time.
  9. Demonstrates a commitment to integrity in work habits and use of SASH resources.
  10. SASH’s mission and operations require that an employee is prepared to perform duties as assigned that may be outside his/her principle responsibilities.

Minimum Qualifications:

  • The Wellness Nurse must be currently licensed as a Registered Nurse in the State of Vermont.  Strongly preferred, at least two years of experience in a clinical setting, committed to an aging in place philosophy.  He/she must have demonstrated leadership skills and the ability to exercise sound judgment.  He/she 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.

Working Conditions and Physical Demands:

  1. Work environment requires a participant centered approach to care.
  2. Employee will be exposed to body fluids, infection, odors, chemicals and cleaning solutions.
  3. Employee will be required to care for some residents who may have difficult behavioral challenges and/or demanding family members and/or guardians.