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.