Community Care Coordinator

3 days ago

Baltimore, Maryland, United States LifeBridge Health Full time

Job Summary:

The Community Care Coordinator plays a vital role in promoting the health and well-being of patients through face-to-face and phone outreach, as well as email communications. As a member of the Interdisciplinary Team (IDT), this role ensures that patients' individual needs are identified and addressed in a timely manner, while respecting their rights and wishes.

  • Develop and implement care plans to address patients' physical and social needs, including assessing and linking community resources.
  • Collaborate with primary care offices to obtain timely appointments for patients, including post-hospital discharge and annual wellness visits.
  • Apply principles of population health management to identify patients with uncontrolled chronic conditions and refer them to the Community Care Manager as needed.
  • Provide care coordination services for patients requiring chronic care management, ensuring timely access to services and respecting patients' rights and wishes.
  • Evaluate and refer patients to the Community Care Manager when acuity changes, following treatment plans written by providers and/or the Community Care Manager.
  • Assess patients in their home environment and assist the IDT in evaluating their needs to facilitate self-management skills.
  • Lead IDT discussions on home management, facilitating home care referrals as needed.
  • Facilitate discussions with patients and family members on advance directives, providing expertise in linking patients with community resources such as prescription assistance.
  • Assist patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other insurance plans.
  • Assess and assist patients' safety needs in their home, ordering equipment as necessary to promote independence.
  • Refer patients or family members to community resources for housing or treatment to assist in recovery from chronic illness, following through to ensure service efficacy.
  • Educate and aid family members in understanding, dealing with, and supporting 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 needed.
  • Review and update provider and Community Care Manager on patients' living conditions and ability to adhere to the plan of care and coordinate treatment goals.
  • Assess, monitor, and evaluate patients' progress in the home with respect to treatment goals, documenting findings in the healthcare record following System-approved protocols.
  • Perform tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
  • Obtain and coordinate access with primary care providers and other specialty providers, 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, including dentists, public health, social services, or other outreach workers needed to provide comprehensive and quality care for patients.
  • Work independently with minimal supervision, performing community outreach activities as assigned.

Requirements:

  • Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience.
  • Preferably with experience working with care managers from acute care settings or health insurance and/or other payer entities.
  • Good verbal and communication skills and organizational skills are a must.
  • Competency in electronic medical records is desirable.
  • Bi-lingual is preferable (market specific).

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