Disease Management Nurse Specialist

1 month ago

Philadelphia, Pennsylvania, United States Spectrum Health Services, Inc Full time
Job Title: Disease Management Nurse

Job Summary:

The Disease Management Nurse will collaborate with patients and healthcare providers across Spectrum Health Services, Inc. to provide chronic-disease self-management support to patients between visits. The nurse will provide in-person and virtual chronic disease self-management education, support a panel of patients in remote monitoring programs, develop educational materials, track program metrics, and participate in collaborative projects with community-based organizations and other health centers to improve the health and wellbeing of Spectrum's patient population.

Key Responsibilities:

  • Work with leadership to develop and implement structured disease management programs, starting with self-measured blood pressure. Future programs will focus on diabetes, asthma, and potentially other chronic disease states, such as CHF and COPD.
  • Track and respond to patient referrals, meeting patients in-person and virtually to enroll in program. Instruct in use of self-monitoring equipment, medication adherence strategies, and lifestyle strategies for self-management.
  • Manage onsite devices and relationship with DME vendor to provide devices to patients.
  • Receive and review telemonitoring results.
  • Provide patient education regarding their medication regimen, medication adherence strategies, dietary strategies for self-management, physical activity strategies for management, and appropriate lifestyle changes such as smoking or alcohol cessation, sleep hygiene, or weight management.
  • Work with patients to develop SMART goals around chronic disease self-management, using motivational interviewing techniques and supportive coaching to assist patients in achieving goals.
  • Conduct proactive outreach to patients at scheduled cadence to check in on self-monitoring and medication adherence, goal progress, and assess for any barriers, issues, or concerns.
  • Serve as intermediary between patient and provider to troubleshoot barriers, issues, and concerns between visits.
  • Flag and review out-of-range readings with provider, work with provider to titrate meds between visits adhering to established nurse-driven protocols, educate patient on regimen changes, and ensure new meds obtained.
  • Field incoming calls from enrolled patients.
  • Work with Director of Clinical Informatics and Quality Measures and Director of Care Management and Population Health to track and report program data.
  • Work with Director of Care Management and Population Health to develop templates to document program data in EHR.
  • Participate in meetings related to HCCN-wide initiatives and grants around chronic disease self-management programs.
  • Work with marketing team and Registered Dietician to develop patient-friendly, health literacy-forward print educational materials and vet pre-made educational resources.
  • Develop Spectrum library of demo devices, including BP cuffs, demo BG monitors, demo insulin pens and administration pads, demo inhalers.
  • Provide one-off education for patients with new chronic disease diagnoses or new medications needed to manage those illnesses.
  • Work with clinical nursing team to orient to demo devices, educational materials, meds, self-monitoring equipment so that they can also provide face-to-face education to patients being seen for visits.
  • Work to obtain free, gently used equipment for distribution to patients with insurance barriers to obtaining equipment.

Qualifications/Experience:

  • BSN degree or higher.
  • At least 3-5 years clinical nursing experience.
  • Strong Microsoft Excel skills.
  • Experience documenting in electronic medical record.
  • Strong knowledge of chronic disease management, including hypertension, diabetes, asthma, CHF, COPD medications, and lifestyle management.
  • Motivational interviewing experience.
  • Ability to interact with individuals with diverse cultural, linguistic, and religious backgrounds.
  • Ability to travel between sites as needed.

Preferred Experience:

  • Experience in home health, ambulatory care, care management, or patient education.
  • Knowledge of public benefits and community resources across Philadelphia.
  • Basic understanding of Medicaid and Medicare durable medical equipment (DME) coverage.
  • Familiarity with remote patient monitoring programs.

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