The Education Nurse is a Licensed Vocational Nurse (LVN) who coordinates and delivers patient education, chronic disease support, preventive health services, and the One Year to a Healthier You (OYHY) program. OYHY is an integrated, community-based chronic disease and cancer prevention initiative serving patients with or at risk for diabetes, hypertension, obesity, and related health concerns.
This role serves OYHY participants and other TAN patients referred for healthcare education. The Education Nurse combines focused nursing care, care coordination, nutrition and wellness education, remote patient monitoring support, and community engagement to help patients understand their health and sustain behavior change. The nurse works across TAN health centers, participates in community events and screenings, and provides LVN coverage in the health centers as needed.
Essential Job Responsibilities
Patient Engagement and Care Coordination
- Receive and process referrals from TAN providers, nurses, and other care team members; serve as the primary contact for referred patients and OYHY participants.
- Complete program intake, collect health histories and biometric information, perform focused nursing assessments, and identify social determinants of health, learning needs, readiness for change, and barriers to care.
- Contribute to individualized care and education plans under appropriate clinical direction; help patients establish realistic goals consistent with the provider’s treatment plan.
- Coordinate appointments, referrals, preventive screening reminders, and follow-up across primary care, behavioral health, and other services; track outstanding needs and communicate barriers to the care team.
- Contact patients after missed visits or education sessions, support reengagement, and maintain patient registries and tracking lists.
- Connect patients with community resources and coordinate available patient supplies and educational materials according to TAN procedures.
Program Delivery and Patient Education
- Coordinate OYHY enrollment, scheduling, education sessions, ongoing follow-up, and completion tracking.
- Provide individual and group education on diabetes, hypertension, weight management, medication use, preventive care, and other healthcare topics based on patient needs and approved educational materials.
- Teach healthy eating using approved plate-method resources, portion control, food label reading, sodium reduction, cancer risk reduction, physical activity, and practical behavior change strategies.
- Reinforce provider instructions, medication adherence, home monitoring techniques, and recognition of symptoms that require contacting the care team or seeking urgent care.
- Adapt education to patients’ language, literacy, culture, resources, and learning preferences; use teach-back and demonstration to confirm understanding.
- Track biometric measures, participation, progress toward goals, and barriers; provide regular motivation and accountability and communicate concerns to the appropriate clinician.
- Support staff education on approved patient education materials, program workflows, prevention topics, and monitoring tools within the nurse’s training and role.
Remote Patient Monitoring
- Coordinate RPM enrollment according to provider orders, eligibility criteria, consent requirements, and TAN procedures; document enrollment and patient education.
- Teach patients to set up and use approved devices, obtain accurate readings, transmit data, and understand when and how to contact TAN; assist with basic troubleshooting and coordinate technical support.
- Review assigned RPM readings and alerts during designated monitoring periods under approved protocols; contact patients about missing data, reported symptoms, adherence, and barriers.
- Promptly report abnormal readings, symptoms, and changes in condition to the supervising clinician according to established escalation procedures; document notifications and follow-up.
- Reinforce clinician-directed instructions and track follow-up. Route clinical interpretation, treatment changes, and urgent assessment needs to the appropriate licensed clinician.
Blood Pressure Visits and Health Center Coverage, as needed
- Conduct blood pressure visits, review medications and home readings, provide education, and communicate findings to the provider according to approved protocols.
- Provide LVN coverage as needed, including rooming, vital signs, focused assessments, assisting with procedures, administering ordered medications and immunizations, specimen collection, and testing.
- Process refill requests and patient follow-up under approved workflows; escalate clinical concerns.
Community Collaboration and Outreach
- Collaborate with community partners and TAN teams to provide health education, screenings, and outreach at community and employer wellness events.
- Promote OYHY and TAN services, connect participants with care and resources, and coordinate event supplies, documentation, and follow-up.
Documentation and Reporting
- Maintain accurate, timely documentation in the electronic health record, including in person, telephone, education, RPM, and outreach related patient encounters as applicable.
- Maintain patient registries and program records; track referrals, participation, biometric measures, education provided, goal progress, and care connections.
- Prepare monthly reports on engagement, outcomes, and service delivery; support grant reporting, required documentation, and outcome tracking.
- Participate in audits, quality improvement, and evaluation of program effectiveness; protect patient information in all records and reports.
- Perform other duties as assigned to support patient care and organizational needs.
Patient Centered Care and Compliance
- Support the PCMH model through coordinated, equitable care, patient education, prevention, and timely communication.
- Practice within LVN scope, competency, provider orders, and appropriate clinical supervision; escalate needs requiring comprehensive assessment or treatment decisions.
- Follow TAN policies and applicable HRSA, HIPAA, OSHA, and infection prevention requirements; complete required training and promptly report safety or compliance concerns.
- Demonstrate TAN’s core values of reliability, collaboration, knowledge, innovation, and compassion.
Core Competencies
- Patient Education: Explains health information clearly and uses practical teaching methods to support self-management.
- Patient Centered Care: Provides respectful, compassionate care that considers each patient’s goals, culture, and barriers.
- Care Coordination and Teamwork: Communicates effectively with patients, clinical teams, outreach staff, and community partners.
- Organization and Accountability: Manages referrals, registries, follow-up, documentation, and reporting accurately and on time.
- Clinical Judgment and Safety: Recognizes changes and concerns within the LVN role and seeks appropriate clinical direction promptly.
- Adaptability: Balances education, monitoring, outreach, and clinical coverage across assigned health centers.
Minimum Education, Qualifications, and Experience
- Graduation from an accredited vocational nursing program.
- Current, unrestricted Texas LVN license or valid multistate privilege authorizing LVN practice in Texas.
- Strong understanding of chronic disease prevention and management, social determinants of health, and health disparities.
- Experience facilitating group education or wellness classes and ability to provide individual patient education.
- Excellent interpersonal, organizational, and written and verbal communication skills.
- Proficiency with Microsoft Office and electronic health record documentation; ability to learn RPM systems and maintain patient tracking tools.
- Ability to work collaboratively, maintain confidentiality, and travel between assigned health centers and community event locations.
Preferred Qualifications
- Bilingual in Spanish and English strongly preferred.
- Experience in community health, chronic disease education, care coordination, or remote patient monitoring.
Work Environment and Physical Requirements
- Work is divided between TAN health centers and community or field assignments; local travel is required for health center coverage, events, and screenings.
- Requires sitting, standing, walking, bending, and reaching during office work, patient care, education sessions, and community activities.
- Requires use of computers, telephones, monitoring devices, and standard clinical equipment; may involve transporting educational materials and supplies.
- Requires dependable attendance, flexibility with assigned locations and scheduled events, and the ability to prioritize competing patient and program needs.
- Essential duties may be performed with or without reasonable accommodation.