Website lanec_careers Lane County Health & Human Services

To promote & protect the health and wellbeing of all individuals

About the Position
Do you have a passion and dedication to caring and advocating for your community and our patients? Do you find yourself energized and engaged when working in an evolving and challenging environment with a focus on continuous improvement? If so, we have an exciting opportunity for you to join a talented and passionate team!

We are seeking a Community Health Nurse to provide a variety of professional population-focused community and public health nursing services in health promotion, prevention and disease control programs; and to perform related duties as assigned.

This position is within our newly established Transition of Care and Access (TOCA) clinic. The Transition of Care and Access Clinic is designed to create an avenue for improved access, quality visits, efficiency, and support with follow up care and improved timely access to care for patients recently discharged from the hospital. The TOCA RN connects with the patients to obtain important information and provide triage to determine how urgently the patient should be seen.

Description of TOCA RN duties: 

  • Retrieves Hospital Discharge Records.
  • Completes intake template.
  • Updates and reconciles medications and allergies.
  • Updates Health Histories.
  • Questionnaires – SDOH/PRAPARE.
  • Follow Up Care (PCP, referrals, DME/Meds, etc).
  • Completes LACE score – assessment tool that measures length of stay, acuity, co-morbidities, and number of emergency department visits in the last 6 months.
    *This assessment identifies patients who are at risk for readmission or death within 30 days of discharge.

This activity supports the care team and provider to focus on the delivery of patient care, developing a supportive care plan around improved outcomes, and engaging in patient education.

Brief Description of other duties: 

  • Performs independent, comprehensive telephone and clinical triaging, and facilitates care coordination through a multidisciplinary approach.
  • Provides patient education as an integral part of the services offered.
  • Acts as relief nurse, triages and screens walk-in patients to assess the severity of the patient’s condition and the need for provider intervention.
  • Communicates with providers regarding determinations and situations, documents events appropriately.
  • Other duties as assigned.

To apply for this job please visit