Performs function necessary to better coordinate and manage patient care services between the hospital and clinic to: enhance quality, address prevention, increase compliance, improve patient satisfaction, maximize efficiency of providers/nurses, and meet ACO, PCMH, and MU indicators. Collaboration with Provider and other members of the PCMH team to provide comprehensive care. Will direct and perform duties to ensure that patient has a pleasant and satisfactory experience in the method in which their healthcare is delivered, managed, and coordinated with internal and external entities while encouraging the patients’ participation in decision making. The position requires total support of the PCMH principles, policies and procedures.
Patient relationship: Will greet and welcome the patient in a pleasant, respectful, culturally and linguistically appropriate manner. Assure all patient questions are answered in a positive and cordial manner. Assures the patient has a clear understanding of all communications. Communicates patient’s problem/complaint to the provider. Reinforces to the patients the importance of keeping appointments or communicating changes in their appointments. Asks the required intake questions for a proper assessment and evaluation of higher level of care management support. Maximizes the components of care coordination and care management to improve patient’s healthcare experience and outcomes by utilizing care coordination and care management tools, criteria and protocols. Engages patient and their care givers in understanding and setting self-management goals and plans in a culturally and linguistically appropriate manner (PCMH 3C) using motivational interviewing, health literacy promotion, and other evidence based tools Performs patient call backs in a timely manner and documents (PCMH 1A). Serves as a patient’s clinical advocate. Verifies that patient’s and family members’ discharge and follow up questions have been addressed and appropriate educational materials provided and documented in the electronic medical records (PCMH 3C). Works with patient and family members to enhance their understanding of the treatment plans on the disease process to include identification of early signs of decline in condition (PCMH 4A). Face to face or by telephone.
Management of patients care: Assists with refills, reviews all patient medications as per protocols. Initiates notes for the nurse on call or others to alert information regarding a patient. Assists the providers as requested. Assists with scheduling tests or treatments as requested. The care manger II discusses the patient’s needs and guides them to meet their needs by assisting in setting self-management goals. Assures that clinical protocols and standing delegation orders are fulfilled for specified patient populations. Conducts review of electronic and clinical records for appropriate utilization of service (PCMH 2C, 3A). Facilitates telephone consultations, provider visits, or face to face visits with patients or care givers for care coordination, care management, assess needs, and/or educate the patient (PCMH 1A). Identifies barriers impacting the patient care and refers to appropriate support systems such as social workers, wellness counselors, etc. (PCMH 3D). Identifies high risk patient for disease management and care coordination and works with patients and the primary care team to establish a plan of care to meet the patients’ needs. Performs duties within the scope of practice as delegated by provider through the use of approved standing orders and or protocols (PCMH 2C). Reviews activities that occur during the patient’s hospital stay, community agencies or at home to coordinate patient’s care (PCMH 5C). reviews discharge planning and coordinates discharge needs with facility, care givers and patients. Facilitates provider contact to coordinate patient’s needs (PCMH 5C). Supports the PCP to implement the integrated plan to achieve desired outcomes and to satisfy contractual/regulatory requirements. Actively participates in performance improvement projects to improve patient care outcomes. Teaches method of health promotion and disease prevention in accordance to individualized needs. Refers patient to appropriate resources/referrals, social services, pharmacy, laboratory, etc. (PCMH 3C). Works jointly with provider to maximize disease prevention and reinforce patient follow through with provider’s orders and instructions (PCMH 3C).
Manages patient information: Performs pre-visit chart reviews for required health indicators, vaccines, labs, etc. Reviews chart under the direction of provider and obtains and places report results in charts. Makes list of anticipated needs for patients (vaccines, labs,etc.) Assures the patient information and records is completed timely and is current. Adheres to all HIPAA regulations in and outside of the Clinic. Communicates patient information as requested to enhance patient services. Provides patient with chronic and acute conditions the support, education, and assistance in the prevention and /or maintenance of their disease and/or health and wellness state and increase patient’s compliance.
Team communication: Meets with the team to ensure that the provider’s productivity and schedule is reviewed and populated throughout the day. Works with unit team members as well as other clinic personnel to ensure a smooth patient flow. Communicates specific patient needs and/or population management information. Engages community resources to support patient’s needs and improve collaborative coordination of care. Actively participates in a multidisciplinary team, huddles to coordinate care, scheduling and follow up along with the provider and front desk clerks to prepare for the patients scheduled, review opportunities for same day access, and alerts other disciplines for patients and families with and without special needs (PCMH 1A, 1B, 1G). Assists in developing in-service training and educational programs. Participate in quality improvement projects aimed at improving patient care outcomes for patients (PCMH 6). Participates in providing training/education/orientation to SC employees or students when requested. Prepares tracking reports regarding hospital admissions and readmissions and reports findings to appropriate committee and primary care team (PCMH 5C). Goal is a post hospital call to patient within 2 business days. Goal for the post hospital follow up visits is within 7 days of discharge excluding deliveries.
Demonstration of safe and professional conduct: Maintains a friendly environment for self and others. Response to emergency situations as per training. Refrains from texting and speaking on the cell phone while on duty. Refrains from informal communication with patients and others. Fully participates in the performance improvement and follows all the Clinic policies and procedures. Attends work on a regular and predictable schedule in accordance with Clinic leave policy and performs other duties as assigned. Performs all duties to ensure the patient has a pleasant and satisfactory experience in the manner in which their health care is delivered, managed, coordinated with both internal and external entities and in which the patient participates in decision making.
A current Texas LVN license required. Minimum of 2 years clinical experience in case management in a healthcare setting. Must be current with BLS/CPR certified. Experience in working with the public preferred. Must be computer literate. Bilingual (English/Spanish) a must.