Registered Nurse - Care Collaborative Lead

The University of Kansas Health System

About The Position

MUST BE LOCAL TO KANSAS and willing to travel 70% of the time. The Collaborative Care Lead serves as the primary point of contact among patients, primary care providers, and the specialty care team to ensure care coordination and ultimately deliver high-quality diabetes care to each enrolled patient. This role will use data insights from the diabetes data dock, along with clinical judgment, to identify patients for intervention and perform patient outreach to facilitate patient care from the patient's care team. The Collaborative Care Lead will partner with primary care teams and the collaborating remote specialty team, including endocrinologists, diabetes educators, pharmacists, nurses, psychologists, and case managers, to deliver personalized care to patients with diabetes living in rural Kansas. The Collaborative Care Lead will be responsible for documenting these encounters and communicating with program leadership and support to ensure that care is delivered as intended and that issues are appropriately escalated. This role will also be highly involved, along with other members of the Diabetes Data Dock team, in developing and refining clinical intervention tools to support this work. This includes collaborating with the technical team to refine dashboards for reviewing diabetes data among those enrolled in the program, developing clinical protocols to guide interventions and escalation, and planning to address the ongoing needs of those enrolled in the program.

Requirements

Bachelor Degree Nursing
5 or more years experience in clinical care
Proficiency in Microsoft Office and Teams

Nice To Haves

Master Degree Nursing
Experience in caring for people with diabetes and those living in rural areas
Certified Diabetes Care and Education Specialist - Certification Board for Diabetes Care and Education (CBDCE)

Responsibilities

Complete team onboarding and training.
Assist in establishing a communication plan to enable collaboration within care protocols with input from Collaborative Care Lead, Local PCPs, and Endocrine team.
Develop program documentation protocol.
Assist in developing an intervention protocol template for addressing patient needs based on risk criteria, available resources (both at KUMC and local), and patient preferences.
Assist in the creation of training materials for specialty clinic personnel (RN, CDCES, PharmD, NP/PA, RD, Psychologists, Case Managers) and participate in the training of these providers.
Assist in identifying and enrolling 4 clinics to contribute patients with diabetes for enrollment in the pilot phase.
Work with local sites to identify patient enrollment criteria and intervention risk thresholds based on patient characteristics, diabetes type, and local resources.
Schedule and complete clinic site visits to each clinic site with the Project Lead.
Based on intervention protocol and with input from Patient, PCP, and KUMC specialty team, collaboratively refine and approve a care plan for each enrolled patient.
Monitor risk dashboard, identify patients at risk, and initiate care plan actions for at-risk patients (expect 1 interaction/patient/quarter @20 participants/site/year @ 4 sites = 320 interactions).
Establish recommended follow-up & referrals to PCP, Endocrinologist, or Ancillary providers and monitor progress of each enrolled patient.
Complete appropriate documentation of care plan and follow-up actions.
Iterate on communication and clinical protocols to enhance & adapt these frameworks.
Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
Other duties may be assigned as required.