Scope of Position:
The R.N. Care Coordinator, as a member of the interdisciplinary iCMP pediatric health care team, works collaboratively with the Primary Care Practice, to enhance the delivery of patient care services for "high-risk" patients along the continuum of health care and across multi-disciplinary sectors. Utilizing a patient-family centered team-based approach, the R.N. Care Coordinator focuses on improving the patient's healthcare outcomes and patient experience, reducing cost of care, and improving provider satisfaction. This is accomplished through the application of institutional standards of high quality patient care, promoting timely access to appropriate and well- coordinated care, increasing preventative services, and facilitates the connection of families to community resources as needed. Through broad knowledge of clinical care and systems management, the Care Coordinator evaluates, predicts, and facilitates the trajectory of patient care.
The position requires a high degree of flexibility, independence, and willingness to participate in multiple activities and provide support to all members of the project team. The position must have strong communication skills and the ability to communicate comfortably with patients and their caregivers, members of the interdisciplinary team, physicians and other practice staff, and program and administrative staff.
Principal Duties and Responsibilities:
Participate in team case reviews to assign appropriate primary care coordinator, identify aspects of the case that require the expertise of other iCMP team members. and provide consultative services to other role groups in the iCMP team.
Performs a comprehensive nursing/psycho- social assessment on a targeted patient population.
Develops and implements a care plan, in partnership with the patient's PCP and other members of the pediatric iCMP team, that address the patient/family stated and clinical goals. Ensures psycho-social barriers are addressed and all elements of the plan have been assigned accountability, and communicated to the patient/family, members of the Interdisciplinary medical team and appropriate community partners.
Engages the family and patient in their health management and care plan by addressing barriers to care the patient and family are experiencing and are hindering their engagement.
Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused and friendly, high quality, efficient, and cost effective.
Influences appropriate utilization of health care resources by coordinating patient care, encouraging involvement in disease and case management programs; conducts follow-up care prior to and post interaction with the broader health care system, including acute care admission, emergency department visits, specialist visits, and sub-acute care settings.
Increase continuity of care by managing relationships with tertiary care providers, transitions of care, and referrals to both in- and out-of-network clinical providers ensuring the patient's medical home is aware of all recommendations made by these parties and reconciles changes made in care, including medications.
Attends patient/family Team meetings in medical, educational and community settings as needed, enlisting the help of other iCMP role groups as appropriate.
Documents in the medical record all relevant encounters with the family and other agencies improving the health and well-being of the child.
Provides consultation and education as necessary to other members of the iCMP care team regarding clinical matters, insurance benefit design and coverage, health care options, and available community resources that would improve the care of a particular patient.
Participates in iCMP Team Meetings, Case Reviews with MGH Pedi ICMP team members, the MGH adult iCMP team and other Partners iCMP teams.
Participate in practice-based Medical Management meetings, as appropriate.
Participates in quality improvement activities of the iCMP program that may include PDSA, giving direct feedback and adjustments in responsibilities to improve the overall function of the program.
Performs other duties as assigned.
Patient Population Served: "The staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit". Check all that apply.
If Pediatric Assignment: If Medical/Surgical Assignment:
__X_Neonates (birth-1 month) X Young Adult (18 to 25 yrs)
__X_Infant Senior Adult (55 to 64 yrs)
_ X_Early Childhood (12 mths-5 yrs) _ Geriatric (65 yrs and up)
X_Adolescence (13 to 17 yrs)
RN with current license to practice in Massachusetts
Graduate of an accredited clinical program is required. (for RNs: BSN strongly preferred; new grads must have BSN)
3 years of clinical experience strongly preferred; Case Management experience preferred.
Strong interpersonal skills with diverse populations and role groups
Effective written and oral communication skills with patients, families, team members and health providers
Demonstrated cultural sensitivity
Required ability to work autonomously and with flexibility
Goal oriented and accountable.
Demonstrated organizational skills.
Demonstrated ability to work in a complex setting.
Ability to work in an interdisciplinary team based environment.
CM Certification desirable
Strong Computer skills
This position requires work and travel between multiple physician practices, community organizations and patients home. Own car required.
Massachusetts General Hospital