The Nurse Care Coordinator’s primary responsibility is to oversee care coordination for the primary care practice’s patients. This includes developing and monitoring care coordination processes and supporting primary clinical teams with these efforts. It also includes identifying the high-acuity patient population and working to ensure care coordination for this patient population. The position may involve some patient triage. The Nurse Care Coordinator will work with the HealthSpan Population Health Manager, Practice Manager and Medical Director (lead physician) of the practice to develop this position to best serve the needs of the patient panel and the primary care teams. The Nurse Coordinator will be responsible for documentation and report development and running to show results of the pilot.
o Planning pre-visit workflow to ensure care completion prior to visit whenever possible.
- Works with all clinical teams as a resource on care management of all the practice’s patients. This includes:
o Coordinating care with hospital, ER, consulting physicians, community resources.
o Developing a workflow to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physician, or by another healthcare provider.
o Providing after-visit summary review with patients whenever appropriate.
o Involving the patients in activities to improve their health (patient engagement).
o Educating the patient about self-management tasks they can undertake to gain greater control of their health status.
o Developing relationship with patient as an integral team member.
- Actively manages assigned panel of chronic care patients (high acuity). This includes:
o Providing follow-up contact with patients as indicated to ensure compliance with recommendations-medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.
o Managing many aspects of patients’ care: referrals to specialists, hospitalizations, ER visit, ancillary testing, and other enabling services.
o Providing telephone advice per protocol, handling urgent calls and emergent calls.
o Anticipating the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.
o Working with patient and patient’s care team to coordinate change readiness, needs, assessment, and develop an individualized treatment care plan.
o Assisting patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reporting abnormal findings to their physician team.
o Collaborating with the patient, physician, and other care team members in assessing the patient’s progress toward individual healthcare goals.
o Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments.
o Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
o Collaborating with payer case managers for additional services when appropriate.
o Developing a list of medical supply and community resources available to patients and maintaining collegial relationships with the entities used most frequently.
o Collaborate with office staff and project team to establish systems for at risk member identification utilizing multiple available tools.
- Develop and document protocols for PCMH delivery model and reporting of outcomes
o Collaborate with office staff and project team to develop and document workflows and protocols for delivery model.
o Establish documentation requirements for delivery of services, tracking of activities and measurement of change/outcomes utilizing office EMR or other documentation process ensure sue of searchable and reportable fields.
o Establish communication processes within offices practitioners/staff re: activities performed. Ensure documentation is consistent and available to all.
o Collaborate with office staff and project team to develop outcome measures and prepare and analyze outcomes reports and progress toward program goals.
Catholic Health Partners - 2 years ago