JOB TITLE: Health Care Coordinator-RN

JOB CODE:

PAY GRADE:

OSHA LEVEL:I

DEPARTMENT: Dartmouth-Hitchcock Wellness Plus

REPORTS TO: Department Director/Medical Director

SUMMARY: Under general supervision of the Director, and under the general direction of the physician/associate provider, perform as a member of the healthcare team. Provide health screening and assess, plan, and coordinate chronic disease care management for employees and dependents. Is knowledgeable of and performs within the scope of practice as delineated by the New Hampshire Board of Nursing.

RESPONSIBILITIES:

1.Conduct a comprehensive nursing assessment of the patient and family.

2.Develop and implement patient care plans.

Development of a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals
Ensure regular updates and revisions to care plan
Provide nursing care via nursing visits at the provider office, via telephone and/or electronic communications.
Assist patient with identification and definition of short and long term goals.
Identify barriers to self management and adherence to recommended treatment.
Communicate care plan with primary care provider or specialty care provider.

3.Coordinate patient care.

Facilitate communication between the patient, family, provider, other practice team members, specialists, other providers, social work, therapists, and community resources.
Ensure completeness of, and access to, patient’s health information and care plan by all appropriate parties.
Identify the patient’s needs related to transitions between care locations and providers of care.
Identify needs of the patients/family and refer to community resources.
Identify needs for a home environment and safety evaluation.

4.Provide patients with self-management support.

Monitor patient health status and patient’s ability to manage his chronic illness regularly.
Monitor patient adherence to preventative care guidelines and facilitate closing gaps in evidence based medicine.
Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.
Perform pre- provider visit planning to ensure productive, effective patient-provider interactions.
Perform post- provider visit wrap-up and between visit contact to ensure patient understanding of the treatment plan, develop patient-specific goals and tactics in order to increase patient’s ability to meet his/her health goals.
Coordinate and conduct patient education.
Counsel and guide a caller through their healthcare choices by accessing the patient education knowledge bases, library resources, Shared Decision-Making videotapes and the Internet for research.

5.Engage in quality improvement projects.

Lead or participate in quality improvement projects for the practice, especially related to the management of patients with chronic illnesses
Maintain skills and knowledge necessary to perform daily work.
Demonstrate proficiency and act as an expert role model in the performance of care coordination.
Meet or exceed standards of performance as established for employment at Dartmouth-Hitchcock.
Seek opportunities to increase knowledge and expertise.
Participate in care conferences regularly and as needed in conjunction with [patients/families, peers, Department Director/Medical Director, and/or the Primary Care Provider.
Take a lead role in mentoring clinical support staff members of their department; assist with training and staff development activities, particularly in areas of clinical expertise. Serve as a resource for colleagues and other members of the healthcare team.
Comply with all DH and departmental policies and procedures.
Attend and participate in meetings as needed.
Assist in the development of department annual goals and the identification of outcomes for continuous quality improvement.

6. Perform other duties as appropriate or assigned.

MINIMUM EDUCATION & EXPERIENCE:
Current State of NH RN license, BSN preferred. Minimum of 3 years experience in a community-based practice or health plan. Current certification in BLS required Excellent assessment, communication, interpersonal, and organizational/ time management skills. Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment and during a crisis and/or emergency. Excellent verbal and written communication skills. Sound decision making, judgment, time management and negotiation skills. Familiarity with electronic medical records, and computer applications including MS Word and Excel. Excellent computer skills. Must demonstrate passion for care of patients with chronic disease. .

PSYCHOLOGICAL CONSIDERATIONS:
Flexibility, tolerance, and demonstrated ability to take initiative and to prioritize multiple tasks with attention to details. Function at a fast pace and continually interact with a wide variety people and situations while maintaining a customer focus. Able to remain focused and function effectively in a crisis situation. Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources.

SUMMARY OF PHYSICAL DEMANDS:

Daily demands may vary dependent on specific duties performed. Up to 80%-100% of day may be spent seated while talking on the phone, attending meetings, completing or reviewing paperwork or working on the computer. Up to 75% of day may be spent working in a repetitive motion activity including use of computer and keyboard to access and input information. Must be able to effectively communicate in person and over the telephone. Visual and auditory skills essential to perform patient assessment duties. Fine motor control may be important to perform injections or other procedures. May bend, stoop, or reach to retrieve materials or supplies, push or pull up to 60 pounds, and assist in lifting patients. Must be able to respond to emergency situations. Some travel may be necessary to attend meetings or training.

Written By:___Sheila Johnson, MBA, RN ______Date: _10-28-2010 _

Approved By:______Date: ______