Works collaboratively with multidisciplinary care team staff across the continuum of care for high risk patients. Provides coordination of care and disease management longitudinally to patients with chronic condition(s) or episodic care of a surgical population. Focuses efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness, decreasing preventable ED visits and readmissions while improving patient satisfaction.
Identifies which patients in the specialty care practice have ongoing care coordination needs for their specialty condition.
Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved.
Utilizes assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of social support, readmissions, ED visits, surgical episodes, etc.) to ensure timely and efficient care delivery across the continuum of care.
Utilizes technological tools (registries, patient lists, care team tab, etc.) to manage populations.
Conducts comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral pharmacy, social and end of life needs of each patient.
Informs the patient and family regarding coordination of their care and shares this information with the healthcare team.
Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
Monitors patient compliance with plan of care.
Performs reassessments regarding patient progress toward goals and updates plan of care as appropriate.
Ensures care gaps are closed around specialty disease/chronic disease/surgical episodes.
Serves as primary patient contact for team related to condition/surgical episode and facilitates access to services.
Coordinates members of the patient care team.
Serves as the liaison between patients, families, and physicians, clinical staff by advocating for patient and families then responding to and facilitates resolution of patient/family questions and concerns.
Assists in managing transitions of care across care setting, ensuring optimal communication and planning. Identifies barriers to receiving care and facilitates solutions.
Partners with other care coordinator teams such as primary and transitional care social work, rehabilitation, pharmacy, palliative care and others.
Defines and ensures compliance with disease-specific care paths for specialty care or chronic disease.
Works with the patient and family to assess current knowledge, health literacy, and readiness to change, utilizing teach back to assess level of knowledge.
Coaches patient and family on self-management support; including setting long and short term goals.
Educates about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks. Educates and connects to other care providers and community resources to enhance care.
Works with practices on quality and process improvement initiatives.
Other duties as assigned.
Current state licensure as a Registered Nurse (RN).
Specialty certification preferred.
Basic Life Support (BLS) through American Heart Association (AHA).
For Homecare and Hospice field staff only, must have valid Ohio Driver's license upon hire; per policy 8-175 thereafter.
For Homecare and Hospice field staff only, must have proof of automobile insurance coverage with $100,000/$300,000 coverage, upon hire; per policy 8-175 thereafter.
Complexity of Work:
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
Requires full range of motion, manual and finger dexterity and eye-hand coordination.
Requires corrected hearing and vision to normal range.
May requires some exposure to communicable diseases or bodily fluids.
Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.
Personal Protective Equipment:
The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic's Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.
Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities