Care Coordinator Advance Illness Program

Job Overview:

Facilitates advanced care management for an identified client population to improve quality of life , prevent re-hospitalization and/or provide social connection. May coordinate patient care services for seriously ill patients through collaboration with the patient , family, caregivers and health care providers in achieving optimal quality of life. As a collaborating member of the palliative care team provides pre-visit and follow-up direction and support to the patient, family, and health care providers. As a member of the social connection team, provides advance care planning, telephone social support and information on community resources. Develops relationships with professional colleagues within the community to enhance the palliative care team /social connections team and the services provided. High level focus on empathic communication, customer service and continually strive to perform duties of their job in a manner that will result in optimal patient and provider satisfaction. Contributes to process improvement activities and program data collection. 

Job Requirements:

Associate's degree or diploma in Nursing
RN 
Registered Nurse
Strong oral and written communication skills 
Customer service skills 
Ability to work with physicians and other professional colleagues 
Ability to collect data, generate reports, and provide analysis 
Comfortable working with computers and with EMR
3-4 years experience Clinical Nursing 
Two years of care management experience or equivalent experience in the healthcare environment required
Hospice/Palliative care experience highly preferred
Home health experience preferred 
2-3 years experience Professional Nursing Community health, palliative or hospice care 

Job Responsibilities:

Guides the multi-disciplinary palliative teams. Works collaboratively with members of the healthcare team to coordinate the comprehensive plan of care for residential palliative care patients and families, and support care transitions across the continuum of care. Proactively coordinates patient and family needs between providers and other members of the healthcare team. 
Collaborates with the interdisciplinary care team, primary care provider, and other providers in the care team (specialty consults, home health agencies, DME teams, and hospice team) to achieve continuity of care and coordination of palliative services. Communicates with all relevant service lines to ensure collaboration across the care continuum. Identifies intrinsic/ extrinsic barriers (education level, language barriers, financial concerns, and family dynamics) relevant to the patient's care, as well as families and other resources. Supports goals of care initiated by APRN and facilitates hospice referrals, as needed.
Gathers data and assesses patient care needs. Callaborates with the APRN to support ongoing assessments of physio-biological, cognitive/ emotional, spiritual, and social needs while managing life with advanced illness. Identifies problems that could lead to crisis situations and collaborates with APRN to support goals of care. Actively participates in interdisciplinary team discussions and provides input to provide the best service for patients. 
Promotes evidence-based practices with personal growth and outreach to others. Provides teaching to patients and families related to patients' goals of care and treatment plans. Is accountable for mandatory education requirements and professional growth through organizational and national educational opportunities, such as certification, and shared new knowledge with the advanced illness teams.
Utilizes performance improvement techniques to implement changes which result in improved patient care and office operations. Provides leadership for and participates in the continued development of the care coordinator role within the physician practice. 

Other Job-Related Information:

The TriHealth Nursing Vision, Mission, and Philosophy speaks to professional development, collaboration, and our nursing culture. To achieve excellence in nursing care, TriHealth encourages: pursuit of improved knowledge through continuing education classes, formal education leading to advanced degrees, and the attainment of specialty certification; nurse membership in local, regional, and national nursing organizations related to the appropriate nurse specialty; involvement in activities that better the health of our community; nursing research activities and use of evidence-based practice, and all nurses to foster, support, and personally model collaborative relationships amongst nurses, physicians, and other caregivers for the betterment of patient care.

Working Conditions:

Climbing - Occasionally
Concentrating - Frequently
Continous Learning - Frequently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Rarely
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Frequently
Sitting - Frequently
Standing - Occasionally
Stooping - Rarely
Talking - Consistently
Thinking/Reasoning - Frequently
Use of Hands - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"

• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist

• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…

• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met

• Offer patients and guests priority when waiting (lines, elevators)

• Work on improving quality, safety, and service 
Respect: ALWAYS…

• Respect cultural and spiritual differences and honor individual preferences.

• Respect everyone's opinion and contribution, regardless of title/role.

• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…

• Value the time of others by striving to be on time, prepared and actively participating.

• Pick up trash, ensuring the physical environment is clean and safe.

• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…

• Acknowledge wins and frequently thank team members and others for contributions.

• Show courtesy and compassion with customers, team members and the community

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