Wellness Nurse


Position Overview

The Wellness Nurse (WN) is a three-year, grant-funded position under the U.S. Department of Housing & Urban Development’s 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, 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.  


  • 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 resident’s 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.  


  • 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.

Required/Minimum Qualifications

  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.  
  2. Ability to translate medical jargon into easily understandable lay language and to communicate at appropriate literacy and cognitive levels.
  3. Aptitude in providing education on health and functional conditions commonly experienced by older adults.
  4. Understanding of and sensitivity to the needs of low-income older adults and persons with disabilities.
  5. Ability to self-direct and work independently, but also function well as part of a team.
  6. Ability to multi-task and establish priorities in a sometimes busy and stressful environment.
  7. Ability to establish positive and collaborative relationships with residents, staff and community-based providers.
  8. 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.

Preferred Skills

  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 individual’s 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 [add in key languages at property].




Overall Considerations for SSD Staff Candidates


The position descriptions for the ESC and WN detail desired skills and qualifications for each position. SSD sites may want to consider the following when they interview and weigh their new applicant options for either position. Since the SSD site will contract the WN from an external entity, they may not have the opportunity to directly interview potential WNs. However, they could potentially still use some of these thoughts to guide a discussion with the contracting entity to help ensure the selected WN has the desired qualities and skills for the position.

While these considerations are primarily intended to help the demonstration sites consider new candidates for the ESC position, they could also be used to consider whether the site’s current service coordinator has the needed skills and capacity for the enhanced position and is an appropriate fit. These considerations highlight some of the key functions the ESC will need to be able to fill and abilities they will need to possess.


General Considerations for ESC and WN Candidates


  • Flexibility. While the job descriptions indicate preferred licensure/degree levels and qualifications, demonstration sites will need to balance their decisions based on candidate availability and the best mixture of qualifications and skills. For example, if a particular geography experiences a tight labor market for RNs, sites may need to consider an LPN/LVN if the candidate has relevant experience, skills, and can perform all the necessary functions required.
  • Ability to work independently. The ESC serves as the central communicator and coordinator for the SSD. Within the guidelines set out by the demonstration, they will oversee execution of the demonstration components. While the ESC will have the support of the SSD implementation team and support from the housing organization, depending on its structure, the ESC will generally work on his or her own on a daily basis. The ESC must feel comfortable working independently and self-direct. Similarly, the WN will serve as the sole health and wellness professional at the building, and will need to prioritize and guide their own work appropriately.
  • Collaboration. While the ESC and WN positions are largely self-directed and conduct a large portion of their work independently, the ESC and WN must also work together as a team to collaboratively address residents’ needs. They need to communicate regularly, collaborate on identifying ways to address resident and community needs, fulfill their individual responsibilities, and respect each other’s work and opinions. Included in this is the need to also communicate and collaborate with provider and partner organizations, when applicable.
  • Communication.  A key element of effective team work includes establishing effective communication strategies between all involved parties, including the ESC, WN, property staff, partner organizations, providers, and residents and family members. At the center of this strategy will be near constant contact between the ESC and the WN regarding demonstration progress and issues that need resolution.


  • Ability to foster sustainable relationships. ESCs and WNs must build trusting relationships with residents so that they can encourage and motivate residents to participate in programs and follow-through on suggested advice and activities.  Having some understanding and appreciation of the culture and preferences of the low-income older adults in the property can help facilitate connecting with residents.
  • Knowledge of community resources. The ESC and WN will begin assessing resident needs and helping them to identify services and resources to help address those needs soon after launching the program. ESC and WN teams that bring some understanding of the resources and programs available in the community will have an advantage in being able to support residents more quickly.


WN Candidates


  • Ideally, the wellness nurse should have experience in community nursing. The WN does not provide direct clinical care, but serves as an educator and coach to help residents understand their health conditions, help build their ability to self-manage their chronic conditions, and encourage them to adopt healthy behaviors. They also consider the social determinants that affect the resident. In addition to working with residents one-on-one, they identify and develop opportunities for group wellness and prevention programming. While the wellness nurse uses their clinical observation and assessment skills, he or she will focus on ongoing wellness and prevention.




Potential Interview Questions


This section provides potential interview questions for the new ESC or WN candidates. Since the SSD site will contract the WN from an external entity, they may not have the opportunity to directly interview potential WNs. However, they could potentially still use some of these questions to guide a discussion with the contracting entity to help ensure the selected WN has the desired qualities and skills for the position.


The interviewer(s) should select from the questions below and add others, as appropriate, based on a candidate’s resume and the need for further elaboration.


ESC and WN Interview Questions


  • What attracted you to apply for this position?
  • What leadership positions have you held, professionally or personally, where you brought together a group with shared interests, led meetings, and produced results?  If you haven’t been that leader yet, give us an example of someone you admire for their leadership skills and describe what skills you feel are most important to a leader.  
  • Do you have experience with evidence-based programs, such as the Stanford Chronic Disease Self-Management Program or Matter of Balance?  If so, could you discuss which ones you have worked with? Are you trained or certified to deliver any such programs?
  • If the candidate has worked with older adults as demonstrated in their resume, ask them to describe in more detail the nature and scope of their work, if needed.
  • Have you had any experience working with individuals with mental health, behavioral health or drug/alcohol abuse concerns? If so, could you describe your experience? Are these issues you feel comfortable working with? Are you aware of potential services and resources to assist individuals with such concerns?
  • What about any experience working with diverse populations and individuals from different ethnic and racial backgrounds, including working with non-English speaking adults? If yes, in what context did this occur?
  • Do you prefer to work independently or in a team or group environment? Give an example of a time when you’ve been in a job with limited supervision and how you managed your time and handled tasks. Is that a comfortable role for you to be in? Why or why not?
  • Do you have any experience with conducting assessments of individual’s health, functional, or supportive service needs? In instances where you might have to ask more personal or probing questions, is that something you feel comfortable with?
  • Do you have any experience with the concept of person-centered care where the participant partners in the development and execution of his or her goals and support plan? If so, could you please describe?
  • Have you had any experiences where someone has pressed you for private or confidential information regarding an individual that you are not able to share? Can you talk about how you have handled those situations? 
  • Tell me about a time when you had a caseload of work to complete, but then an emergency with a resident or client occurred. How did you handle dealing with a crisis while still completing your daily work?
  • Describe a time when you had to have a difficult conversation with a resident/client. What was it about? How did you deal with it?
  • How do you build a relationship with someone who has let you know they don’t want any help or are not interested in the assistance you offer?
  • Tell me about agencies you know that support elderly and persons with disabilities. Do you have any experience working with them? Do you have any established relationships with staff of these types of organizations?
  • Have you had any experience building partnerships with community organizations or other service providers? Is so, can you describe any of the partnerships, how they were established, and how you worked together?
  • A component of the job includes documenting information about residents and program activities in a database. Have you ever used a database or software program for your work?  If yes, please describe. Are you comfortable working with computers in general?