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RN - ACO/Population Health
4 months ago
*This position will work at the Mahomet, Rantoul, and Monticello Family Practice Locations*
The Population Health Nurse will promote effective partnerships between patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and effectively manages care transitions and facilitate a "shared goal model". He or she will partner with the provider care team for successful preventative care visits to reduce the severity of chronic disease and avoidable acute illness. He or she will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risk.
- Core Values consistent with patient/family centered approach.
- Demonstrates professional and effective written and verbal communication skills.
- Proactively acts as a patient advocate.
- Recognizes, identifies and responds to opportunities for improvement.
- Demonstrates effective learning skills based on established, evidence based practice guidelines.
- Mentoring and coaching of other team members.
- Cultivates effective partnerships will all members of the patient care team.
- Delegation of appropriate work and skills in order to optimize and streamline workflows and interoffice resources.
- Provide a coordinated, strategic approach to identify new or manage an established chronically ill patient population.
- Stratify patient population according to risk to effectively and efficiently manage patients. Determine frequency of need for provider appointment and CCM encounters. Maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
- Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/timely provider visits, and CCM non-face-to-face monthly encounters.
- Ensure all required elements are documented for CCM and related AWV component billing.
- Ensure office staff has an effective internal tracking process to capture results, medication acquisition, missed appointments, and adherence to follow-up appointments.
- Develop a process to track Annual Wellness Visits (AWV) scheduling and ensure that patient records are reviewed appropriate to identify care gaps prior to visit with the provider visit. Post reminders to secure that all co- morbidities are discussed and documented during AWV.
- Participate in huddles with provider and care team. Identify scheduling opportunities, determine special needs for patients arriving that office/clinic day, identify patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments needing rescheduling. Ensure sharing of positive patient stories or compliments involving care team efforts.
- Provide clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease. Effectively partner with provider practice team members to mobilize needed community resources for the patient and family.
- In collaboration with the physician or qualified healthcare provider, develop a care plan based on mutual goals with the patient, family, the provider, and emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
- Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
- Attend and participate in all Care Coordination related trainings and meetings as assigned. Participate and monitor PI metrics.
