Comprehensive Care Specialist

23 hours ago

Baltimore, Maryland, United States LifeBridge Health Full time
Job Title: Comprehensive Care Specialist

At LifeBridge Health, we are seeking a skilled Comprehensive Care Specialist to join our team. This role is responsible for promoting the health and well-being of assigned patients through face-to-face and/or phone outreach, as well as e-mail communications.

Key Responsibilities:

  • Contact patients, caregivers, and families to ensure preventive services are received by assigned patients
  • Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients, including post-hospital discharge and annual wellness visits where appropriate
  • Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to the Community Care Manager accordingly
  • Provide care coordination services for patients requiring chronic care management
  • Ensure that appropriate patients receive an annual physical exam and/or annual health risk assessment (HRA), including completion of required documentation by payer contract
  • Evaluate and refer patients to the Community Care Manager when acuity changes
  • Follow treatment plans written by providers and/or the Community Care Manager
  • Assess patient needs in their home environment and assist the Interdisciplinary Team (IDT) to evaluate the patient's ability to improve self-management skills
  • Lead IDT discussions in home management of assigned patients, including facilitation of home care referrals where appropriate
  • Facilitate discussion with patients and family members on advance directives
  • Link patients with community resources, such as prescription assistance programs
  • Assist patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other insurance plans
  • Assess and assist patient safety needs in the home, i.e., fall risk and order equipment as necessary to promote patient independence
  • Assist with medication self-management, i.e., setting up medication boxes if needed
  • Refer patients or family members to community resources for housing or treatment to assist in recovery from chronic illness and follow through to ensure service efficacy
  • Educate and aid family members to understand, deal with, and support patients with chronic illnesses and end-of-life practices
  • Interview clients about activities of daily living to determine needs and link with community resources as appropriate
  • Review and update provider and Community Care Manager records of patients' living conditions and ability to adhere to the plan of care and coordinate treatment goals
  • Assess, monitor, and evaluate patient progress in the home regarding treatment goals
  • Document findings in healthcare records following System-approved protocols
  • Collect data, maintain records, develop, and utilize assessment and measuring tools relative to patient care and wellness practices
  • Obtain and coordinate access with primary care providers and other specialty providers, including behavioral health, ensuring necessary records and documentation of referrals are completed and reconciled
  • Educate patients on availability of resources for primary care and acute care, as well as alternative community programs and services that promote sound health, lifestyle, and well-being
  • Schedule timely and appropriate office and follow-up visits at or with other healthcare providers, such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients
  • Work independently with minimal supervision
  • Participate in community outreach activities as assigned

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