Annual Wellness Nurse/Population Health Facilitator - LPN

Fisher-Titus Medical Center•Bellevue, OH

3d•Hybrid

About The Position

The Annual Wellness Nurse/Pop Health Facilitator works collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules. This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. The AWN is responsible and accountable for direct and indirect patient care for designated patient populations. Although, primarily performed by a LPN, the role of an Annual Wellness Nurse can be accomplished as an RN with understanding that salary will be established at an LPN level.

Requirements

Expertise in the nursing process
Critical thinking skills to plan and coordinate care
Responsible and accountable for direct and indirect patient care for designated patient populations

Nice To Haves

Can be accomplished as an RN with understanding that salary will be established at an LPN level.

Responsibilities

Communicate with populations of patients via telephone, electronically, correspondence or otherwise to support patient adherence to plan of care and/or evidence-based medicine guidelines.
Maintain an active case load of "at risk" patients using identification and stratification tools, direct referrals from the patient's healthcare team (physician, Care Coordinator, hospital case manager, etc.) and other clinical knowledge.
Work with "at risk" patients and families on self-management support including: Setting short and long-term goals for self-management of chronic disease. Addressing medication adherence in patients not meeting outcome goals. Creating a plan for health behavior change.
Performing individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
Communicating with patients face-to-face, by telephone, or by email.
Communicating a plan for healthcare needs between physician/office visits.
Providing needed patient education regarding specific health care skills and general disease concepts by supplying informational materials, directing the patient to health plan resources, approved websites or community resources.
Working toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
Floats and/or works at other locations to support operational needs.