Works collaboratively with multidisciplinary care team staff across the continuum of care to provide care and disease management to high risk patients identified in the ambulatory setting. Focuses efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness, decreasing preventable ED visits and readmissions while improving patient satisfaction.
Identifies which patients in the specialty care practice have ongoing care coordination needs for their specialty condition.
Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved.
Utilizes assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of social support, readmissions, ED visits, etc.) to ensure timely and efficient care delivery across the continuum of care.
Utilizes technological tools (registries, patient lists, etc.) to manage populations.
Conducts comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.
Informs the patient and family regarding coordination of their care and shares this information with the healthcare team.
Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
Monitors patient compliance with plan of care.
Performs reassessments regarding patient progress toward goals and updates plan of care as appropriate.
Ensures care gaps are closed around specialty disease/chronic disease.
Serves as primary patient contact for team related to condition and facilitates access to services.
Coordinates members of the patient care team.
Serves as the liaison between patients, families and physicians, clinical staff by advocating for patient and families then responding to and facilitates resolution of patient/family questions and concerns.
Assists in managing transitions of care across care settings, ensuring optimal communication and planning. Identifies barriers to receiving care and facilitates solutions.
Partners with other care coordinator teams such as primary and transitional care social work, rehabilitation, pharmacy, palliative care and others.
Defines and ensures compliance with disease-specific care paths for specialty care or chronic disease.
Works with the patient and family to assess current knowledge, health literacy, and readiness to change, utilizing teach back to assess level of knowledge.
Coaches patient and family on self management support; including setting long and short term goals.
Educates about managing a specialty condition, including prevention and health maintenance tasks. Educates and connects to other care providers and community resources to enhance care.
Works with practices on quality and process improvement initiatives.
Other duties as assigned.
Internal Number: 601
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