LPN | Primary Care Clinic

Hillsdale Hospital•Hillsdale Township, MI

5d•Onsite

About The Position

This role in a Primary Care Clinic focuses on providing a coordinated and strategic approach to patient care, particularly for those with chronic diseases and health/social needs. The LPN will collaborate with patients, families, and healthcare providers to develop and manage care plans, improve health literacy, and facilitate access to community resources. The position involves monitoring patient progress, acting as a liaison between providers, and ensuring adherence to care plans and health IT systems.

Requirements

Current Michigan licensure as an LPN
Experience in caring for patients with chronic diseases is required
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed
Must be proficient in communication and computer technologies (email, cell phone, etc.)

Nice To Haves

Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health
Previous experience with health IT systems, ERMs and data reports

Responsibilities

Provides a coordinated, strategic approach to detect early, assess, and manage effectively the chronically and/or mentally fragile patient population's unmet health and social needs
Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care
Provides effective communications to improve health literacy for patients/families
Coaches patients/families towards successful self-management of their chronic disease
Acts as liaison between PCP and Specialists on patient condition as needed between office visits
Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan
Monitors patient adherence to plan of care and progress toward goals, and facilitates changes as needed
Promotes healthy behaviors in all populations and ensures navigation assistance with community resources
Assists in outreach to patients made after they have been seen in ED or inpatient stay
Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources
Enrolls patient in Medicaid and assists with other community resource referrals
Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
Facilitates and attends meetings between patient, families, care team, payers, and community resources
Ensures all VBR and MSSP metrics are met
Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites