Lead RN Care Coordinator (4 days a week)

Salary Range : $58,000.00 To $76,000.00 Annually

Key Details

Schedule : 4 days a week, 32 hours a week.

Location : Essential, on-site role at 421 Fallsway Main Clinic

Number of Direct Reports : 1

Status : Exempt

Overview

The Lead RN Care Coordinator delivers and oversees care management services for medically and / or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Lead Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Lead collects and analyzes patient-level data, assists with development and maintenance of care plans, and evaluates outcomes of interventions. This role will supervise other members of the MDPCP Care Team, including the Care coordinator(s).

What You'll Do

• Trains and coaches’ staff, sets clear expectations, monitors outcomes, creates a culture of open communication and helps team members solve complex problems through individual supervision and team meetings. Fosters a collaborative, supportive and collegial environment across departments.
• Manages a caseload of high-risk patients with chronic conditions, providing complex case management. This may include referrals to chronic disease case management, supporting transitions of care, high risk clinical tracking, and ensuring access to complex medication management.
• Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients. Involves the client in the development and implementation of an integrated treatment plan.
• Works collaboratively with care teams to maximize quality of life as well as reduce avoidable admissions, re-admissions and ED visits. Follows up with MDPCP clients following an ED visit or hospital admission. Helps the Agency monitor and reach out to other health center clients in need of ED or hospital follow-up.
• Delivers health education and counseling, drawing upon the individual’s strengths and motivation to explore lifestyle choices, preferences, and safety concerns.
• Perform clinical tasks as appropriate based on license and training including health education groups.
• Completes clear and timely documentation within electronic health record in a manner that is consistent with MDPCP and agency standards.
• Oversees AHEAD model’s (e.g. MDPCP) day-to-day operations to ensure success of the program including :

Leads and organizes MDPCP-related events including patient and family advisory council, Completing risk stratification as required to identify clients deemed “high-risk” and in need of care coordination services. Leads and organizes outreach plan to high-risk individuals, Providing expertise to care management functions across the agency including additional populations identified for needing care management services regardless of payer source, Reviewing

Knowledge, Experience and Skills

Formal Education and Training

Experience

Skills

Key Agency Responsibilities

In addition to role responsibilities, each staff member of Health Care for the Homeless has the following responsibilities as a part of their employment :

Why Join Us?

Read more and apply here : https : / / workforcenow.adp.com / mascsr / default / mdf / recruitment / recruitment.html?cid=301a5408-a748-42d5-9892-8deaccf9d270&ccId=19000101_000001&jobId=532425&lang=en_US

About Health Care for the Homeless :

Locations :

Baltimore City – Downtown - 421 Fallsway, Baltimore, MD 21202

Baltimore City – West Baltimore - 2000 W. Baltimore St., Suite 3300 Baltimore, MD 21223

Baltimore County - 9150 Franklin Square Dr., Suite 301 Baltimore, MD 21237

Our Vision

Everyone is healthy and has a safe home in a just and respectful community.

Our Mission

We work to end homelessness through racially equitable health care, housing and advocacy in partnership with those of us who have experienced it.

Our mission : "...to prevent and end homelessness for vulnerable individuals and families by providing quality, integrated health care and promoting access to affordable housing and sustainable incomes through direct service, advocacy and community engagement."

Over 35+ years, we at Health Care for the Homeless have steadily grown and strengthened our approach to care to meet the needs of the vulnerable people we served. We are driven by a single and unwavering goal : to improve access to care for clients, and to provide them with the highest possible quality of care. Continuing in that spirit, we are now implementing a care model that takes quality and access to a new level.

A health home delivers person-centered, whole-person care that is evidence-based, uses data and listens to clients to continuously improve the care we deliver. We have been person-centered and focused on the whole person since the first client walked through our clinic doors in 1985. We’ve also always applied evidenced-based standards to our work and used data to inform our care.

What’s changed is how much we’ve grown over the years : We have more disciplines, staff members and sites. Coordinating all of our activity today requires a more powerful and standardized way of delivering care.

We are a health home.

Five areas of focus

As a health home, we apply five (5) clinical areas of focus to the care we deliver.

ACCESS FOR THOSE WHO NEED US

People should be able to reach us easily when they need help. So we ensure 24 / 7 access to clinical advice; make our appointment schedules and hours flexible and accommodating; and enable clients to access their health records electronically. We also are increasing our presence throughout the community. We have clinics in dowtown Baltimore, West Baltimore and Baltimore County. And we are continually expanding our street outreach and reaching more people with our mobile clinic.

TEAM-BASED CARE

Whole-person care requires the expertise of many different providers. Done well, it demands collaboration and constant communication among these providers. We are integrating our care providers into multidisciplinary care teams, each with a “panel” of clients, so they can develop care plans that span the range of treatment and services with clients.

CARE MANAGEMENT

Not only are we committed to providing clients with the best possible care; we are committed to positioning them to manage their own care. To that end, we make sure we know which client groups have the highest needs; we share clients' care plans with them and across their care teams; we provide clients with the tools to care for themselves and we make sure they are part of all decisions relating to their care; and we help them manage their medications.

BETTER MANAGE AND COORDINATE CARE

People experiencing homelessness often have complex conditions that require intensive care coordination. Our providers specialize in identifying these particularly vulnerable individuals. They provide them with the multi-disciplinary support that keeps them out of hospital emergency rooms, and they help them develop reasonable, healthy goals for themselves. This coordinated and comprehensive care includes helping individuals put a roof over their heads.

IMPROVE THE HEALTH OF THE LARGER POPULATION

As a population, people without homes have higher rates of chronic disease, such as diabetes, than their housed counterparts. We are using evidence-based guidelines to standardize and expand our assessments for these conditions. And we are continuously seeking ways to help our clients manage and treat their conditions.

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Person-centered, whole-person care

We provide person-centered, whole-person care, combining health care services and supportive services with advocacy.

We provide whole-person care in a safe, respectful environment with acute sensitivity to clients’ life experiences. All have endured trauma; many engage in behaviors that pose a risk to their health. Through a trauma-informed and harm reduction approach, we meet individuals where they are, engage them in care with dignity and work to engage them fully in their own overall wellness.

TRAUMA-INFORMED CARE

Trauma is central to the homeless experience. People without homes often experience life trauma before they end up on the street, and living on the street is, in itself, traumatic. Trauma affects everything from our ability to trust others and build relationships to our brain development. For these reasons, we at Health Care for the Homeless are committed to providing trauma-informed care, a best practice that recognizes the impact of violence on an individual’s well-being, and that helps heal the social and psychological wounds violence leaves in its wake.

HARM REDUCTION

Total adherence or abstinence doesn’t work for all who engage in behaviors harmful to their health, like substance use. Harm reduction leverages the relationship between the care provider and the individual to lower the individual’s health risks. Our providers work with individuals to set goals that both reduce harm and are realistic to achieve.

Our model of care is known in the health care industry as a patient-centered medical home. Because we provide comprehensive care that goes beyond medical care, we call ourselves a health home.

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Health Care for the Homeless is Participating in the Maryland Primary Care Program (MDPCP)

Our practice is participating in the MDPCP, a state-wide initiative to improve primary care. To help us provide you with the best care, Medicare will share some of your personal health information with HCH and the State Designated Health Information Exchange (CRISP), to share with other health professionals providing care to you. This will provide us with a more complete picture of your health and allow us to better coordinate your care.

For further information and to opt out of data sharing, read more here.

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Health Care for the Homeless is accredited for quality : Health Care for the Homeless is an FTCA-deemed facility and is accredited by the Joint Commission for ambulatory care and behavioral health, and as a patient-centered medical home.

We invite you to apply and join a welcoming team.