LPN Care Manager - Mettowee

COMMUNITY HEALTH :

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties.

ABOUT THE ROLE :

The Care Manager will collaborate with patients that have been identified through risk stratification. The care manager then supports the patient, their families and care team members to help a patient manage their medical conditions and co-occurring behavioral health, psychological and social determinants of health through the healthcare system. The Care Manager supports patients who are moving between health care practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change. It includes community resources and services that the Care Manager will collaborate with patients identified through risk stratification, focusing on emergency room and inpatient discharge follow-ups, inpatient readmissions, transitions of care, and geriatric patient health needs. The Care Manager supports patients, their families, and care team members to manage medical conditions and co-occurring behavioral health, psychological, and social determinants of health through the healthcare system. The Care Manager supports patients transitioning between healthcare practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings as their condition and care needs change. This includes community resources and services that support a patient through one level of care to another.

FUNCTIONS OF THE POSITION :

• Provide follow-up care to all identified patients based on their level of complexity, social determinants of health, and the identified stratification tool.
• Collaborate and coordinate care with any potential post-discharge concerns or barriers that have been identified.
• Provide transitional care to risk-stratified patients post-discharge from either outpatient or inpatient venues.
• Ensure that hospital-discharged patients have adequate education and knowledge of their medication list.
• Determine the frequency of telephone encounters based on specific patient needs.
• Identify barriers to care (including social determinants of health) for care-managed patients and reach out to appropriate resources based on patient needs.
• Determine at any time that a patient requires a face-to-face visit.
• Utilize an identified schedule to follow up with their patients.
• Follow up with all identified care-managed hospital discharge patients who do not keep their appointments and provide additional follow-up based on patient needs.
• Make referrals to the Care Manager whenever a primary nurse or provider identifies a complex or high-risk patient, irrespective of whether the patient has been hospitalized.
• Review patient lists to identify patients requiring care management services.
• Work with Visiting Nurses, SASH, Council on Aging, VCCI, RMH, various support groups, and any other member of the healthcare team or community stakeholders as necessary.
• Assist patients identified as needing intense care / chronic disease management with individualized programs on an ongoing basis.
• Develop a panel of patients who need care management services by creating a care plan to improve their health outcomes (e.g., CCM, ACO, CM).
• Actively participate and collaborate in managing patients that require home health visits.
• Assist with transitions of care for patients moving to or from home, hospital, rehab, or other facilities, including non-care managed patients.
• Complete designated self-chart audits.
• Comply with required expectations for consistent documentation of care management services provided.
• Provide follow-up care for patients discharged from the emergency room, inpatient discharges, and inpatient readmissions.
• Specialize in geriatrics, assisting elderly patients with challenges through individualized programs and ongoing care management.

SKILLS REQUIRED FOR SUCCESS :

HOW WE SUPPORT YOU :