LPN Care Coordinator- Homecare

Carilion Clinic•Radford, VA

About The Position

The LPN Care Coordinator provides care management for specific patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation, maximizing coordination and facilitating patient/family movement through the system. Applies protocols when appropriate and facilitates referrals, providing linkages to health and wellness resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care. LPN position. Working with Homecare patient base. Company equipment. Mileage reimbursement. The Care Coordinator (LPN) Coordinates care and services within care managed population. Collects patient/family data to assist in identifying individualized care management needs. Implements plan of care interventions as identified by the Care Team and communicates with clerical and clinical support staff to coordinate activities to meet care needs using evidence-based protocols. Works with Care Team to identify individual care management needs. Huddles daily with Care Team for pre/post-visit planning to identify those patients who need close follow up, resources, additional education, and support. Documents needed interventions on providers schedule ie necessary labs, patients in poor control or who may need intensive education in-house or through referral. Coordinates plan of care and services, directing liaison activities to appropriately integrate the patient into the health care continuum. Monitors plans of care/pathways/practice guidelines to ensure that expected patient outcomes are achieved within appropriate time frames and utilizing effective resources. Facilitates Interdisciplinary Team Meetings. Provides feedback to the health care team verbally or via chart entries related to the patients progress toward reaching expected outcomes or about barriers to the plan. Coordinates changes to the plan as necessary. Documentation in the medical record is completed in the appropriate time frame and accurately reflects the plan of care and care management interventions planned or completed. Facilitates physician documentation of data that accurately reflects the patients condition, co-morbidities, treatment and procedures that support the most appropriate status. Facilitates an Interdisciplinary Approach to patient care. Facilitates continuity of care using multidisciplinary collaboration and coordination of appropriate health care services and community resources across the care continuum. Maintains effective communications with all disciplines. Prioritizes patients with chronic diseases/ outlier patients for appointments and/or forwards list to appointment desk to schedule patients. Conducts follow-up with identified patients: those with inconsistent follow up, recent hospitalization or ED visits, or those identified as having significant barriers to self-management or care coordination. Coordinates and manages all care transitions with a focus on comprehensive, accurate, and effective communication. Supports patient/ caregiver self-management and behavior change using motivational interviewing and coaching. Engages and empowers patient/ caregiver as an active participant in disease/ condition management. Determines readiness/ willingness to change based on protocols and partners with patient/ caregiver/ care team in identifying goals, plan of action. Identifies and tracks patient/ caregiver capacity for and confidence in self-care. Supports patient/ caregiver in adopting healthy behaviors and promotes lifestyle changes. Advocates for the patient and family throughout the entire episode of care. Provides focused, individualized patient/ caregiver education using evidenced based content and self - monitoring tools with teach back to ensure understanding. Assists patients/families with benefits/resources management. Communicates with patients/families to ensure understanding of third-party payer guidelines and financial implications of care plans. Maintains and updates community resources. Provides these to patients when appropriate, following up on referrals. Participates in department and system performance improvement initiatives. Uses protocols to evaluate the effect of care coordination and interventions on quality outcomes. Performs concurrent medical record reviews in assigned area. Reviews and tracks relevant patient data in accordance with accepted Disease Guidelines. Runs outlier reports for ongoing chronic care patients. Using protocols and approved guidelines, evaluates the effect of care management on quality outcomes and fiscal parameters. Documents utilization review in accordance with departmental guidelines. (Database/Disease registry management). Actively participates in quality improvement projects.

Requirements

Education: Graduate of an accredited school of practical nursing.
Experience: 5 years of recent experience in a physician practice or clinic.
Licensure, certification, and/or registration: Current license to practice practical nursing (LPN) in the state of Virginia. AHA BLS-HCP required in practices where the Care Coordinator provides direct patient care. Case Management or Care Coordination Certification required within one year of hire.
Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: positive interpersonal oral communication skills; effective written communication skills; analytic skills; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team. Also demonstrate knowledge and competency in computer literacy; community and system resources; effective interpersonal relations; analysis and research methods. Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.

Responsibilities

Coordinates care and services within care managed population.
Collects patient/family data to assist in identifying individualized care management needs.
Implements plan of care interventions as identified by the Care Team and communicates with clerical and clinical support staff to coordinate activities to meet care needs using evidence-based protocols.
Works with Care Team to identify individual care management needs.
Huddles daily with Care Team for pre/post-visit planning to identify those patients who need close follow up, resources, additional education, and support.
Documents needed interventions on providers schedule ie necessary labs, patients in poor control or who may need intensive education in-house or through referral.
Coordinates plan of care and services, directing liaison activities to appropriately integrate the patient into the health care continuum.
Monitors plans of care/pathways/practice guidelines to ensure that expected patient outcomes are achieved within appropriate time frames and utilizing effective resources.
Facilitates Interdisciplinary Team Meetings.
Provides feedback to the health care team verbally or via chart entries related to the patients progress toward reaching expected outcomes or about barriers to the plan.
Coordinates changes to the plan as necessary.
Documentation in the medical record is completed in the appropriate time frame and accurately reflects the plan of care and care management interventions planned or completed.
Facilitates physician documentation of data that accurately reflects the patients condition, co-morbidities, treatment and procedures that support the most appropriate status.
Facilitates an Interdisciplinary Approach to patient care.
Facilitates continuity of care using multidisciplinary collaboration and coordination of appropriate health care services and community resources across the care continuum.
Maintains effective communications with all disciplines.
Prioritizes patients with chronic diseases/ outlier patients for appointments and/or forwards list to appointment desk to schedule patients.
Conducts follow-up with identified patients: those with inconsistent follow up, recent hospitalization or ED visits, or those identified as having significant barriers to self-management or care coordination.
Coordinates and manages all care transitions with a focus on comprehensive, accurate, and effective communication.
Supports patient/ caregiver self-management and behavior change using motivational interviewing and coaching.
Engages and empowers patient/ caregiver as an active participant in disease/ condition management.
Determines readiness/ willingness to change based on protocols and partners with patient/ caregiver/ care team in identifying goals, plan of action.
Identifies and tracks patient/ caregiver capacity for and confidence in self-care.
Supports patient/ caregiver in adopting healthy behaviors and promotes lifestyle changes.
Advocates for the patient and family throughout the entire episode of care.
Provides focused, individualized patient/ caregiver education using evidenced based content and self - monitoring tools with teach back to ensure understanding.
Assists patients/families with benefits/resources management.
Communicates with patients/families to ensure understanding of third-party payer guidelines and financial implications of care plans.
Maintains and updates community resources.
Provides these to patients when appropriate, following up on referrals.
Participates in department and system performance improvement initiatives.
Uses protocols to evaluate the effect of care coordination and interventions on quality outcomes.
Performs concurrent medical record reviews in assigned area.
Reviews and tracks relevant patient data in accordance with accepted Disease Guidelines.
Runs outlier reports for ongoing chronic care patients.
Using protocols and approved guidelines, evaluates the effect of care management on quality outcomes and fiscal parameters.
Documents utilization review in accordance with departmental guidelines.
Actively participates in quality improvement projects.