Care coordination is the deliberate organization of patient care activities to facilitate the appropriate delivery of health care services. This position advocates, guides and intervenes on behalf of the patient population PCCN serves in coordination with the PCP to support patients/families in understanding and navigating the health care system. Care coordination needs are identified through patient assessments and used to develop a plan of care. The plan of care identifies problems, develops goals to improve the health and well-being of patients and families, and outlines interventions to reach these goals and promote self-sufficiency. This position works closely with the rest of the Care Management Team to coordinate and track implementation of care plans, assist with problem resolution and troubleshoot barriers to care. This position works independently, receiving supervision of work activities from the Care Team Supervisor and Manager of Care Management.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- a) Administers Health Risk Assessments (HRAs) with patients/families who may be eligible for PCCNs care management services.
- b) Works with patient/family and other members of the care team to develop plans of care.
- c) Identifies and coordinates needed referrals for specialty care, behavioral health, community services and/or social work.
- d) Works closely with Care Navigators, assigning tasks to implement and track the plan of care.
- e) Conducts status meetings with patients/families.
- f) Monitors and evaluates patient/family success with meeting established goals and revises care plans accordingly.
- g) Makes discharge from care management determinations based on goal completion.
- h) Escalates unresolved barriers to the Care Team Supervisor or Manager of Care Management.
- i) Maintains timely, complete and accurate documentation in compliance with regulatory policies and procedures.
- j) Supports initiatives to improve quality performance against pre-defined gap in care and utilization metrics.
Interdisciplinary Care Team
- a) Cultivates and maintains effective interaction/communication with members of the interdisciplinary care team.
- b) Leads interdisciplinary care team meetings, reporting on desired and actual patient health outcomes and facilitates discussion to create action plans as necessary.
- c) Creates or approves communications sent to the interdisciplinary care team.
Transitions in Care
- a) Calls patients/families transitioning home from a hospital stay within specified time frame to monitor and support execution of the post-discharge plan of care, identify and address any additional needs with the goal of reducing the likelihood of re-admission.
- b) Supports medication compliance and treatment adherence.
- a) Maintains professional competency by regularly participating in a variety of educational programs and in-services, reviewing relevant professional publications, participating in community based committees related to service line responsibilities, and/or participating in professional societies to ensure ongoing awareness of current methodologies, practices and philosophies as applied to the patient care population.
- a) Communicates clearly in both written and verbal communications with all internal and external customers.
- b) Provides excellent service routinely in interactions with all internal and external customers.
- c) Responds to email within 24 hours or one business day.
- Performs miscellaneous job related duties as requested.