This job exists to: Provide self management through education, goal setting and follow up to patients .
ESSENTIAL DUTIES AND RESPONSIBILITIES:
o Prenatal, including tracking of all OB outcomes and delivery information
- Manage Planned Care on the Pod as per Registry Workflows and respond to support needs on the pod during the day.
o Newborn visits
o Weight loss counseling
o Basic nutrition counseling
o Well Child Checks (1 year always & when provider requests)
o Tobacco Cessation
o Chronic disease self management and goal setting with all Planned Care patients
o Discussing a1c and lipid results w/Pts over the phone and set goals with patients to improve these numbers
o Group visit advertising, marketing, creation and trouble shooting
- Facilitation of patient Group Visits
o Patient recruitment and scheduling, in collaboration with clinic staff
o Preparation of group materials for education and activities
o Set up/tear down of GV space
o Facilitation of patient-group discussions
o Provide Health education as needed based on group needs/type
o Anticipatory Guidance as defined by protocol
o Basic diagnosis-specific education for Planned Care diagnoses
o Identify all OB patients on Medicaid and screen for eligibility
o Complete comprehensive intake on all eligible patients
o Provide continuity care throughout pregnancy in collaboration with BHP, RD, and PCP
o All PN+ patients should see CM or BHP at each visit as appropriate
o Confirm all data has been entered correctly and completely in the EMR
o Submit completed shadow chart to supervisor for billing log
o As requested by PCP; use these opportunities to refer to higher-level resources as appropriate
- Brief behavioral health interventions (lower-acuity patients)
o Goal setting and education
o Depression (PHQ score within scope) in conjunction with the Behavioral Health Professional
o Stress management and relaxation techniques
o Support Behavioral Health Professional, PCP or RN in crisis intervention:
§ Domestic violence
§ Child abuse & neglect
§ Suicidal ideation
o Teen confidentiality
o Pregnancy decision counseling
o Facilitate transfer of higher-acuity patients to BHP
o Referrals to community resources as per Resource Cards
o In conjunction with the ACO Home Visit Provider, conduct home visits with designated Clinica ACO patients in the Boulder/Adams county areas to provide coordination of care for patients after discharge and facilitate handoff to primary care team
- Demonstrate knowledge of the principles of growth and development over the life span.
- Accountable Care Program:
o Document home visit in EMR according to protocol
o Manage HARMS 8 task box to conduct and document HARMS 8 Risk Assessments with designated ACO patients according to protocol
o Manage a list of “Never Before Seen” patients who have been assigned to CFHS per ACO but have not yet been seen at CFHS – offering CFHS services, create patient chart, schedule appointments and document per protocol
A. Education / Experience
1. BA degree in Human Services field or equivalent experience.
2. Experience providing health education is preferred.
B. Knowledge, skills and abilities:
1. Excellent verbal and written communication skills in English and Spanish required.
2. Ability to flourish in a team management system.
3. Sensitivity to low income, ethnic minority community.
4. Excellent organizational skills.
5. Excellence attendance.
6. Ability to flourish in an unpredictable daily flow.
7. Ability to/interest in providing health education and support in an individual and group setting