Clinical Care Coordinator

SUMMARY

Connecticut Children's Center for Care Coordination (the Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children but enhances the care giving capacity of families.

The clinical registered nurse coordinates and provides comprehensive care coordination to all children/families. Clinical Care Coordinators are able to provide appropriate and enhanced services to children with complex medical needs because of their knowledge and experience in pediatric nursing. There is also a critical focus on children with behavioral and mental health conditions as well as those who are vulnerable.

*Utilizing the care coordination process, this position is responsible for providing targeted care coordination services to a group of complex chronic pediatric patients and their families across the continuum of care. The Clinical Care Coordinator assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the family and other members of the health care team.

ROLE RESPONSIBILITIES

Direct Care Coordination: 50%

Identify families that will benefit from care coordination services

Assess for medical/dental, behavioral, developmental, educational, and social support needs

Develop family centered care plan

Access & Secure critical medical and behavioral services; connect families to community services/ resources

Monitor outcomes & satisfaction

Communicate with Primary Care Providers

Convene case conferences

Advocate for appropriate services (i.e. educational services, etc.)

Provide transition services to adult care

• Participates in the Targeted Chronic Disease Management Program "Better Health" process by: assessing patient/family needs, communicating needs to multidisciplinary team, and reporting recommendations back to referral source.

Utilizes care coordination process by:

• assessing patient/family needs in hospital, home, or other community location
• establishing and implementing a plan to proactively facilitate achievement of outcomes through communication with patient/family and health care team to coordinate care
• ongoing planning to achieve individualized patient/family outcomes
• evaluating patient/family outcomes to continuously update the plan

documenting plan and interventions

• Advocates for patient/family within the health care system and community.

• Provides enhanced targeted care coordination services to support complex chronic patients in specific conditions but not limited to (Asthma, Diabetes, Trauma, and Behavioral Health Disorders) through outreach target calls and intent follow up to their care.

Collaborates/partners with community/state agencies to increase effectiveness, efficiency & health outcomes while decreasing duplicity, redundancy and cost

Supports the family to become active participants in their child's health care program and provides ongoing support to patient/family as needed.

In collaboration with an Inpatient Case Manager, communicates with family and health care team to assist in the provision of coordinated, cost effective care during a child's inpatient stay.

Assesses a child for the need for medical care coordination and connect with the child's Primary Care Provider

Strives for care to be provided in a quality, cost-effective context. Identify gaps and address issues that negatively impact access to care, services, and resources

Collaborates with any other case managers, care coordinators, and social workers working with a patient/family from payer, community agencies, schools, etc. to insure continuity of care and to avoid duplication of services.

• An average of 50 + active cases for ongoing chronic targeted disease management with follow up care coordination needs including but not limited to support Discharge Readiness Evaluation Solutions, Strategies (DRESS) Complex Chronic patients. This Clinical Care Coordinator will be involved in assessing and supporting inpatient children/young adults, whose complex medical, social, or familial situations are currently, or have the potential to, impact their ability to have an appropriate and safe discharge.

Documentation: 20%

Heavy documentation required in various databases

Utilizes database for assessment, case planning, and evaluation via multiple systems.

Focuses coordination of care on maximizing a patient/family's available resources (both financial and social/emotional).

Education and Advocacy: 10%

Empower families to direct the care of their children within the medical home model or other care delivery system; support non-clinical staff around medical care, terminology/diagnosis, and standards of care

Building Center Capacity: 20%

Actively participate in all center activities, including PDSA cycles, daily management system, care coordination meetings, forum development, research pilots, etc.

EDUCATION and/or EXPERIENCE REQUIRED

RN with BA/BS-BSN Perferred

LPN with 3-5 years of care management experience

Knowledge of complex, chronic pediatric patients that is generally acquired through 2 years of pediatric experience.

• Requires cross training in Case Management for support when needed.

LICENSE and/or CERTIFICATION REQUIRED

Current State of Connecticut licensure required

• Certification as a Case Manager and experience in case management strongly desired.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

KNOWLEDGE OF:

Community resources/social services

Demonstrates knowledge of the population-specific differences and needs of patients in appropriate, specific populations from neonate through adolescence and applies them to practice.

Demonstrates knowledge of disease/diagnosis specific conditions, treatments and care.

Demonstrates knowledge of medical systems and providers.

Demonstrates cultural sensitivity in all interactions with patients/families and co-workers

SKILLS:

Self-directed, autonomous, able to perform tasks with minimal oversight

Working with clinical providers as a part of the multidisciplinary team

Experience in working in clinical or community setting with children and families

Ability to identify care outside of normal parameters

Excellent written and verbal skills

Time management and organizational skills

Computer technology- data entry into program databases

Patient/family teaching skills

Competence in providing developmentally appropriate care and services

Conversational Spanish preferred

ABILITY TO:

Ability to work with families of all racial/ethnic, cognitive, and socioeconomic backgrounds.

Demonstrates knowledge of disease/diagnosis specific conditions, treatments and care.

Demonstrates knowledge of medical systems and providers.

Ability to work collegially and collaboratively with all disciplines.

Ability to work within boundaries of professional practice.

Ability to travel to off-site locations throughout the State, if needed.

Work Environment:

Non-clinical work environment.

• Some patient contact on hospital units, emergency department, and in ambulatory settings.