Summary of Responsibility:
This position will be responsible for managing all aspects of patient-centered care for a panel of frail elderly patients with multiple complex conditions. The nurse directly leads the care management team and interfaces with physicians, health care teams, patients and their caregivers as needed in managing patient care. Assists in providing patient empowerment through the use of motivational interviewing skills, problem solving and self-management goal setting.
- Has a working understanding of patient care delivered in the ambulatory setting and also values the vision and strategies of Population Health to become more accountable for better care, better experiences and reduced healthcare costs for the populations being served.
- Identify and engage appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
- Ability to execute core care management duties:
- Comprehensive assessment: bio-psycho-social-spiritual
- Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning
- Implementation of care plan;
- Collaboration with community partners, such as VNA agencies, caregiver programs, DME providers and social service agencies;
- Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
4. Has knowledge of common chronic/complex medical conditions presented in the population served and is able to:
- Educate the patient on their medication conditions and medications, and build their self-management skills;
- Use motivational interviewing to promote behavioral change;
- Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
5.Development and communication (with patient, caregiver and primary care physician/health care team) of a comprehensive care plan and patient action plan/goals of care based on evidence-based best practice for complex illness.
6.Pro-active management and follow-up (home visits and by telephone) according to care plan that includes incorporation of self-care and shared decision making in all aspects of patient care.
7.Coordination of skilled care with home care nurse, communicating home care notifications and authorizations to the health plan.
8. Coaching patients in the development of self-management goal setting and behavior change skills for attaining their goals.
9. Management and coordination of all transitions in care for complex patient panel:
- Communicates care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialist).
- Ensures that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialty care).
- Directs caregiver support, including ad hoc telephone advice.
10. Facilitation of patient and caregiver access to community resources relevant to patient’s needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, etc.
11. Identifies gaps in care and assists with performance improvement opportunities to close such gaps.
12. Attends required meetings and participates in committees as requested and assists with special projects as needed.
13.Cultivates positive relationships with all patients, customers, guests, and members of the care team.
14. Educates patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.
15. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
- Performs other duties as assigned.
The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.
QUALIFICATIONS AND COMPETENCIES:
- RN required; BSN preferred
- Current unrestricted RN licensure from the state in which practice will occur. May be required to obtain additional licensure in secondary state.
- Three or more years of experience, preferably in a care coordination or nurse navigation role or alternatively, in an ambulatory setting
- Excellent organizational skills required, with the ability to communicate and work collaboratively with all levels of staff, payors, providers and office staff, and effectively utilizing all resources available.
- Must be adaptable to unpredictable situations in a patient care setting while effectively managing assigned duties with precise attention-to-detail, accuracy and follow through, with minimal supervision.
- Maintains strict confidentiality with patient information in a professional manner.
- Ability to use computer software and Microsoft Office applications, including Excel spreadsheets, is required.
- Understanding of nationally recognized standards of care, managed care methodologies, and an awareness of dynamics occurring within the healthcare delivery system are key components of this position.
- Ability to perform job with integrity and values consistent with the organization’s Mission, Core Values and Standards.
- May be required to work embedded within provider practice as patient needs and volume dictate.
- Ability to travel to hospitals, skilled nursing facilities, patients’ homes, and other sites where patients receive care (as indicated by patients’ needs).
- Knowledge of defined area of nursing and allied health services. Familiarity with state-of-the-art developments in medical field.
- Knowledge of federal and state laws relating to nursing/clinical care, professional ethics related to the delivery of nursing/clinical care.
- Knowledge of risk assessment, health status indicators, multicultural factors, and community health issues.
- Skill in collaborating with colleagues, providers, and patients to assess health needs of specific populations, developing strategies and specific programs to address these issues, and making presentations.
- Must possess excellent interpersonal skills, with a flexible and creative approach to problem solving. Ability to facilitate discussion and build consensus.
- Excellent communication skills both written and verbal, and an ability to listen and be assertive, as required. Ability to communicate effectively with variety of internal and external groups.
- Skill in diagnosing and treating complex clinical cases as consultant to other providers.
- Skill in staying on top of trends in medical field serving as proficient role model.
- Ability to analyze complex data and draw conclusions needed to develop clinic policy and procedures.
- Demonstrated ability of working effectively as a patient of an interdisciplinary team, displaying good, clinical judgment and decision-making skills.
- An ability to work independently is essential.
Physical and mental requirements:
Concentrates, organizes efficiently and independently organizes work. Assumes cross coverage responsibilities. Physical effort involved in walking to conduct interdepartmental business. Position requires ability to occasionally lift light objects; frequently performs moderately difficult manipulative, gross body coordination and hand-eye coordination tasks; walks, stands and sits for prolonged periods; sees objects closely and hears normal sounds with some background noise. Ability to frequently concentrate on fine detail with interruption and attends to tasks for more than 60 minutes at a time. Individual must be able to understand and relate to theories behind several related concepts, remember multiple tasks given over long periods of time and be able to communicate in written word using advanced written skills.