Job Description:

Job Description

Complex Care Nurse

JOB SUMMARY:

The Complex Care Nurse will coordinate the provision of care management and care coordination for patients with medically complex issues in the primary setting. In partnership with Amoskeag Health Providers and Practice Care Team staff, the nurse leads care management for medically high risk patients including elderly population with complex medical care needs. Serves to collaborate with specialists, community partners, and community-based organizations, members of the practice care teams and patients/families to ensure the delivery of quality, efficient and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-focused, promoting quality and efficiency in the delivery of care at Amoskeag Health.

JOB RELATIONSHIPS:

Responsible to the Clinical Manager

RESPONSIBILITIES AND AUTHORITIES:

Using Chronic Care Model and other evidence-based guidelines, provides direct services to patients in target populations (high risk, complex medical needs, including vulnerable elderly population at high risk for complications) to coordinate establishment of self-management goals, assistance with disease management, education around medication management, and referrals to necessary/ supportive services.

Educate patients on signs and symptoms, the importance of quickly reporting concerns to their provider, the importance of attending follow-up and referral appointments, medications needed, and other healthcare needs. All information communicated to patients should be documented in the medical record.

Assist with managing patients post-discharge (inpatient, residential, SNF, incarceration and emergency visit) to ensure follow-up plan of care established and communicated to patient/family.

Have processes to track and follow-up on screening and diagnostic tests and specialty appointments. Work with providers to ensure that the results and next steps are addressed in a timely way.

Participates in care coordination and nursing department meetings and others as appropriate.

Works with providers to develop/modify treatment plans that provides for continuity of care, particularly for medically and behaviorally challenging patients.

Engage patients in the health decision-making process and educate/facilitate advance care directives.

Encourage patients to have regular screening exams and follow up to ensure patients receive recommended screenings.

If patients refuse recommended screening or treatments or other important aspect of treatment plan, educate patients on the importance of following recommendations and risks of not following them, and document discussions.

Tracks patient progress on self-management goals and progress with service coordination efforts for high-risk patients.

Coordinate complex referrals, tests, prior authorizations, DME and related care coordination needs with patients health insurance, care coordination from the health insurance team, and other team members.

Follow all patient concerns and symptoms to resolution. If a patient's symptoms do not improve after initiating treatment, work with provider for an alternative plan of care/diagnosis may need to be considered.

Works closely with primary care team (providers, nurses, medical assistants, interpreters and business office) to coordinate PCMH model and provide individual patient care.

Maximizes relationships with referral agencies.

Maintain accurate, timely documentation in the patient's medical record of contacts, case planning, and patient's plan of care.

Provide clear written and oral communication to both Amoskeag Health patient and employees.

Attend and participate in meeting requirements of Amoskeag Health funding sources as indicated. This may include, but is not limited to assisting with development, implementation and monitoring of grant proposal. Attend and participate in other Amoskeag Health meetings as directed. If absent, responsible for reading of minutes and signing the documentation.

Attend mandatory safety-related and infection control in-services as designated by Senior Management.

Maintain licensure for current RN status by ongoing professional education.

Sensitivity to cultural diversity of population being served. Maintain client age-related competence.

Other responsibilities as assigned by supervisor.

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