Statement of Duties
To provide and to facilitate quality care to homeless and at-risk individuals in a dignified, positive and appropriate manner. The purpose of this position is to provide care management within the scope of licensure for high risk patients as determined by Duffy Health Center. Responsibilities include developing, implementing, coordinating and evaluating integrated care plans to promote effective education, self-management support and timely health care delivery to Duffy patients. The aim is to achieve optimal quality outcomes.
The essential functions or duties listed below are intended only as illustration of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if work is similar, related, or a logical assignment to the position.
- Collaborates with providers in identifying appropriate patients for care management based on risk stratification.
- Interviews patients for complete medical histories.
- Designs integrated plan of care that addresses the patients identified needs based on assessment of physical, emotional and social needs and in collaboration with patient and family. Be able to interpret the care plan to the patient and family.
- Evaluates the effectiveness of the plan and determines patient progress with the care plan and treatment. Revises the plan as needed to reflect changing needs and goals. Principle manager of the Care Plan.
- Facilitates follow up patient care, appropriately documenting patients’ needs through symptoms, physical signs, assessment and plan.
- Provides on-site consultation to providers related to implementation of Medical Home Model including tracking processes, implementing clinical practice guidelines and work process/patient flow improvements. Follows up with providers as appropriate.
- Assists in coordination of care with the provider including following up tests, imaging and specialist’s consults for high risk patient groups identified.
- Meets agency productivity standards.
- Identifies and utilizes and refers to community resources specific for the patient/family.
- Collaborates with other healthcare team members including Behavioral Health and Case Management to optimize clinical outcomes.
- Assesses and develops patient education material.
- Develops clinical reports for use in primary care office records, allowing provider support of patient behavior change.
- Builds and maintains disease registry in collaboration with Health Information Technology (HIT) Coordinator and provides feedback to providers on their panel.
- Attends Patient Centered Medical Home meetings.
- Conducts support staff training with the Medical Director regarding Patient Centered Medical Home.
- Other duties as related to Patient Centered Medical Home achievement.
Work is performed under the general supervision of the Medical Director. The employee plans and carries out the regular work in accordance with standard practices and previous training, with substantial responsibility for determining the sequence and timing of action and substantial independence in planning and organizing the work activities, including determining the work methods. The employee solves most problems of detail or unusual situations independently. Instructions for new assignments or special projects usually consist of statements of desired objectives, deadlines and priorities. Technical and policy problems or changes in procedures are discussed with supervisor. Work is generally reviewed only for technical adequacy, appropriateness of actions or decisions, and conformance with policy or other requirements.
The employee has access to confidential medical records and patient information.
The work requires examining, analyzing and evaluating patients and determining treatment plan to be recommended within the limits of standard or accepted practices. Guidelines include a large body of policies, practices and precedents which may be complex or conflicting, at times. Judgment is used in analyzing specific situations to determine appropriate actions. Employee is expected to weigh efficiency and relative priorities in conjunction with procedural concerns in decision making.
Errors could result in delay or loss of service, or improper or compromised patient care.
The position has constant contact with patient, co-workers, and outside organizations, in person, via email and on the phone. The purpose for contact is to conduct examinations, collect data and information, advocate for patients, and give or receive information and assistance.
Recommended Minimum Qualifications
Physical and Mental Requirements
Employee works in a healthcare office and is required to walk, sit, talk/listen and use hands more than 2/3rd of the time; and stand, bend, and reach up to 1/3rd of the time. Employee occasionally lifts up to 10 lbs., and seldom lifts up to 30lbs. Normal vision is required for the position. Equipment operated includes medical equipment, office machines, and computers. Employee may be exposed to biohazards, disease, hostile individuals and/or situations.
Education and Experience
A candidate for this position must have a Bachelor’s Degree in Nursing; and at least three years of experience in a direct patient care in a clinical setting. Previous case/disease Management experience preferred.
Licenses and Certifications required
Must be licensed as a Registered Nurse in the State of MA, and successfully complete the credentialing process.
Knowledge, Skills and Abilities
A candidate for this position should have:
- Compassionate patient care philosophies
- Nursing theory and practice
- Rules, regulations and policies of the health care facility
- Care management protocols
- Creative problem solving
- Proficient use of electronic medical records
- Computer use and Windows software (a high degree of proficiency)
- Interacting effectively and appropriately with homeless and at-risk individuals
- Protocols for handling emergency/crisis situations
- Examining and treating patients
- Analyzing data for population health management.
And ability to:
- Think critically and analytically
- Work independently and with a team
- Effectively handle multiple priorities simultaneously in a timely manner and re-prioritize
- Demonstrate excellent written and verbal communication
- Accurately collect and record information, prepare reports and information
- Record patient information timely in the electronic medical records system
- Quickly identify and prioritize patient needs and provide structured and focused support and interventions
- Work collaboratively with clinical and administrative personnel
- Work in a fast-paced environment with a complex patient population
- Establish and maintain strong, effective and therapeutic relationships with patients
- Sit and work on a computer for moderate periods of time
- Interact effectively and appropriately with at risk individuals and a diverse population, including homeless and drug addicted patients
- Commit to the philosophy and mission of Duffy Health Center which serves the homeless and at-risk population