Primary Care Case

1 week ago

Harvey, United States Family Christian Health Center Full time

Reporting to the Care Coordination Supervisor, the Primary Care Case Manager (PCCM) collaborates with the clinical team, community resource providers, and others to improve the quality of life for patients and their families through coordination of care and service utilization. KEY ACCOUNTABILITIES Patient Care - Develops, implements, coordinates and evaluates health care plans with interdisciplinary care teams to improve access to care, decrease hospitalization and ensure quality care is administered to all Family Christian Health Center Adult Medicine, OB-GYN and Pediatric patients. - Facilitates access to patient-centered, comprehensive healthcare, school and community'based services for FCHC Adult Medicine, OB-Gyn and Pediatric patients and their families; assists patients and families in developing natural resources and making contact with social support networks; and develops resources as appropriate to meet patient/family needs in their community. - Coordinates the need for services through a comprehensive assessment using PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.
- Assigns patients to appropriate provider/service based on individual assessment. - Schedules and follows up with office visits and assessments. - Coordinates post-partum and newborn follow-up care. - Collaborates with other health care providers, community service agencies, and programs to coordinate services.
- Travels to outreach locations to meet with clients/families, coordinate services, and attend regular staff and management meetings. - Maintains personal contacts with patients as needed to ensure compliance with prescribed treatment plans. - Tracks and manages patients for compliance for appointments, referrals and consultations. - Co-facilitates Care Team meetings with providers.
- Meets monthly with Care Team members. - Coordinates non-care team activities with the Patient Advocate and Primary Care Case Manager - Collaborates directly with providers in on-going implementation of health care needs for the patient. - Implements initial internal and external referrals per provider, including the following as appropriate: Dental Department; Patient Education, Nutrition, Healthy Start, WIC, Social Service, Psych, Children and Family Services, Tertiary Perinatal and other Network Centers, Home Health, Homemaker services, senior services and assists with Managed Care Organization programs. January, 2021 - Communicates with the affiliated hospital or referral institutions per provider request for records on a monthly basis or as requested, faxes appropriate documents that are necessary for continuity of care.
- Coordinates care with MHN, Medical Home Network, to assist with patient hospital follow-up care. - Maintains patient immunization schedules and provides lists of patients requiring age appropriate immunizations per request of physicians. Administrative and Organizational Duties - Records all activity, including the care team management plan/self-management goals, into the Electronic Medical Record. - Assists in collection, computing and interpreting data for reporting.
- Documents patient service utilization in external spreadsheet form. - Reports all activity to the Care Coordination Supervisor via a monthly report. - Provides monthly reports of care coordination activities and statistics to Care Coordination Supervisor. - Assists in assessing community health related needs and advocates for underserved population in service area.
- Updates, monitors and promotes services in the Resource Handbook. - Networks with community agencies and organizations to promote the services offered by Family Christian Health Center. - Participates in community networks pertaining to pediatric, adolescent, OB and adult health issues. - Assists in training new staff at various project sites.
- Performs a range of associated administrative functions, as needed, such as monitoring budgets, preparing administrative and programmatic reports and correspond

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