With guidance from the local market leadership, the RN Continuing Care Coordinator works collaboratively with physicians, staff and other health care professionals within his/her clinical setting to maintain and improve quality and sustainability within the local market network, this work includes:
- Chronic Disease Management—Develops a plan of care based on a nursing assessment of the patient and their individual circumstances. The plan of care will include patient and caregiver education as well as coordination and collaboration of care with an interdisciplinary team working with that patient. The RN will also be responsible for monitoring the patient’s progress with the care plan.
- Practice Pattern Management—Referral Management, based upon local program criteria.
- Performance Data Interpretation—Participates in development of workflows and audits.
- Evidence-Based Metric (EBM) guidelines / care plans—Implements and hardwires different EBM guidelines in the ambulatory setting as well as facilitating seamless transitions of care between clinic and post-acute settings and between clinic and other health professionals.
Essential Key Job Responsibilities
1. Assessment
- Works with “at risk” patients and families on self-management support including:
- Performing individual needs assessment, care plan design, education, documentation, implementation, and evaluation of outcomes according to state and national guidelines, policies, procedures, and protocols as required.
- Following evidence-based care pathways.
- Coordinating care across multiple provider sites and interdisciplinary teams.
- Working with patients to create a plan of care for health behavior change:
- Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change.
- Helping the patient to identify and overcome barriers.
- Setting short and long-term goals for self-management of chronic disease, empowering the patient, family and /or caregiver to achieve maximum levels of wellness and independence.
- Referring to appropriate services when applicable including but not limited to community resources and services to address the established goals or desired outcomes.
- Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs.
2. Leadership
- Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.
- Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
3. Critical Thinking
- Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.
- Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments.
- Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management.
4. Relationships
- Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.
- Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.
- Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.
May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.
- Concerns or complaints
- Research and recommend appropriate follow-up and or corrective measures
- Identify opportunities to achieve department process excellence through a thorough analysis of available data and involvement of interdisciplinary teams
- Department Audits
- Assist with audits at the direction of the manager
- Consolidate audit results and provide analysis of results
- Day to day operations:
- At the direction of the manager, assist with hiring by organizing peer interviews
- Work in conjunction with management to ensure daily performance of staff supports effective, safe and efficient patient care and department operations
- Mentor new employees meeting weekly with the employee and or leadership to track progress, ensure appropriate communication with team members
- Identifies and actively participates (or leads) projects to assist with team self-actualization
- Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project, provides ongoing support to team members in collecting, interpreting, and communication of data, and developing action plans accordingly.
- Team conferences
- Attend and participate at interdisciplinary team meetings
- Initiate patient care conferences when needed.
- Committee participation outside of operational departmental work
Disclosure summary
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
