The Care Coordinator coordinates the care of high-risk patients enrolled in the Health Homes Program (HHP) by partnering with the patient’s assigned providers, community health workers, and other care team members. The goal is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs are met, with an emphasis on completing linkages to specialty and hospital-based care. The Care Coordinator also acts as an advocate for these patients, links them to other members of the care team to help the patients gain knowledge of their medical conditions and identifies community resources for continued growth toward a maximum level of functioning.
1. Utilize population health management system, electronic medical record, and/or care team recommendations to identify patients needing care coordination (track patient groups and document patient changes in health, communication, and specialty care).
2. Work collaboratively with care team to conduct comprehensive clinical assessments that include medical, behavioral, pharmacy, social, and end of life needs of each patient as necessary.
3. Develop and oversee a comprehensive, individualized, and patient-centered health action plan (HAP) based on the patient’s physical and psychosocial health needs and personal preferences. Assist the patient, either directly or via the caregiver, in executing and reassessing the plan.
4. Monitor treatment adherence (including medication).
5. Work with the patient and family to assess current knowledge, health literacy, and readiness to change, utilizing methods such as teach back and motivational interviewing (trauma informed care practices). Review care instructions in a culturally and linguistically appropriate manner with each patient to ensure high level of health literacy.
6. Educate patients on self-management skills, provide support for lifestyle modifications when appropriate, and assess barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments.
7. Participate in regular case conferences.
8. Accompany patient to office visits, as needed.
9. Capture relevant data and ensure completeness of all HHP reports and deliverables.
10. Serve as primary patient contact for identified conditions and facilitate access to services.
11. Monitor completion of standing orders, routine laboratory orders, and radiology orders to facilitate meeting goals of medical management.
12. Schedule and track appointments, referrals, and patient progress in electronic medical record system. Report on patient progress towards goals as requested.
13. Request and review data from outside providers to ensure that patients are accessing their specialty care appropriately. Ensure that specialty records are obtained in a timely manner.
14. Follow-up with patients by telephone after ER referral, hospital admission, or operative procedure. Assist with discharge planning.
15. Provide outreach and offer services where the HHP patient lives, seeks care, or finds most easily accessible.
16. Connect patient to other social services and supports he/she may need, including but not limited to housing, transportation, advocacy, and others.
17. Advocate on behalf of patients with health care professionals.
18. Perform other duties as assigned.
1. Bachelor’s degree required.
2. Two years of experience in community health or social service setting preferred.
3. English required, Spanish proficient; Bilingual preferred.
4. Preferred experience with Microsoft Office Suite.
5. Must be able to work in interdisciplinary team setting.
6. Effective communication and interpersonal skills with patients and families.
7. Experience working with Electronic Medical Records preferred.
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Eisner Health receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.