Chronic Care Assistant, Population Health Management
2 weeks ago
General Overview
Across the country, governments, employers, and American families have struggled in the face of rising healthcare costs. Efforts historically have targeted narrow programs and patient populations, and while many have succeeded, healthcare costs continue to rise. It's time to take a radically different approach. A new approach involves putting the patient at the center with the goals of improving value and providing better outcomes at lower cost for patients. The Population Health Management (PHM) department at Mass General Brigham is charged with the challenge to drive better value for patients across Mass General Brigham. To achieve its goals, PHM leverages financial and clinical data to examine opportunities, designs and delivers innovative care models using product development and design thinking disciplines, and leverages problem solving, teamwork, and leadership skills to drive ongoing improvement.
The Clinical Care Assistant will provide operational support in PHM clinical operations focused on chronic care management. The role will coordinate care for patients. A chronic condition may include Dementia, Chronic Kidney Disease, Hypertension, Congestive Heart Failure, patients with multiple chronic conditions defined as high risk, or other chronic diseases. The Assistant will interact directly with patients as needed and assist an interdisciplinary team that may include MDs, nurse practitioners, RNs, social workers, community health workers and pharmacists in implementing care protocols for patients living with specific chronic conditions. The Assistant will serve as a central member of a patient's care team and will provide direct service to both patients and their caregivers. The Assistant will be responsible for scheduling regular check in meetings with the patient and possibly their caregiver, completing intakes and assessments, providing education and coaching support about the patient conditions, caregiving skills and emotional support. These interventions will primarily be virtual but may occur onsite at a provider practice.
The Assistant is charged with keeping members of the care team connected and maintaining regular contact with the patient and caregiver. Thus, the role requires strong communication and organizational skills.
The Assistant will use Mass General Brigham healthcare values to govern decisions, actions, and behaviors. These values govern how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration
Principal Duties and Responsibilities
* Conducts initial intake and assessment for patients identified or referred by a primary care clinician
* Delivers patient and caregiver conditions specific care protocols as appropriate.
* Provides education to patient/care giver on disease specific information
* Manages data entry into Mass General Brigham EPIC system (electronic patient medical record) or other patient database.
* Schedules initial patient virtual visit
* Evaluates and tracks patient enrollment status in the program
* Establishes and schedules standard cadence for follow up with patient. Connects patient to appropriate resources
* Manages care coordination needs for patient they are following including social related health needs
* Works closely with programs' interdisciplinary teams in providing patient care
* Supports administrative needs of central team as needed
* Other duties as assigned
Qualifications
* Bachelor's degree preferred with 1-2 years of health care experience (internships and fellowships are considered as experience)
* A combination of education and experience in a healthcare or related setting may be substituted for requirements
Skills, Abilities and Competencies
* Willingness to work with patients and caregivers in both clinic and home settings
* Familiar with local resources and services
* Friendly, outgoing personality
* Solid team player but also an independent thinker
* Strong interpersonal and team building skills. Ability to get work done through others.
* Respect the talent and unique contribution of every individual, culture and ethnic group and treat all people in a fair and equitable manner
* Teaching/coaching skills
* Strong communication and collaboration skills
* Problem solving skills
* Basic computer skills which include a familiarity with Microsoft Office 365
* The Assistant will demonstrate ability to:
o coordinate the activities of others
o communicate clearly and concisely, both verbally and in writing
o remain calm and work well under pressure
o establish and maintain effective working relationships with superiors, coworkers, patients and families.
o work independently
o prioritize and multi-task in a fast-paced environment
o interact with patients from all economic, educational, and social backgrounds
o treat all patients with dignity and respect
A hybrid work model - primarily working at the MGB office in Assembly Row with an ability to flex to remote work or travel to the MGB primary care practice locations, and community settings including patient's home as appropriate based on the needs of the patient and the clinical intervention.
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