The Care Coordinator- Registered Nurse (Milford, Delaware) will coordinate team-based care to provide health services and education to patients and families through effective partnerships with the PCP, community resources and medical professionals, the patient's medical home team, and the Nemours organization. Provides Care Coordination in the Primary Care setting by utilizing critical thinking skills and nursing expertise in order to optimize patient outcomes amongst designated populations within the practice. Works with patients and families to ensure both medical and psychosocial needs are met in order to promote health and well-being. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.
Essential Functions
Assist with the identification of patients in the practice with special health care needs; add them to the appropriate registry and use the registries to plan and monitor care. Monitors and audits patient registries/lists in accordance with NCQA Standards. Assists children with special health care needs and families in obtaining needed care to optimize quality of life and outcomes when possible.
Initiate family contacts and facilitate patient access to, and communication between, physicians and other team members.
Identify patient and family needs, gaps and/or barriers to care and patient/family strengths and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, behavioral health issues, etc. facilitating appropriate connection to resources available to assist the patient and family to meet needs and overcome barriers to care.
Works cooperatively with families, patients, other members of the treatment team, social service agencies, community resources, and public agencies. Collaborates with the family and team to arrange for health care needs. Acts as a liaison for agencies and families with identified healthcare needs.
Utilizes the nursing process to coordinate the care of an identified population of pediatric patients throughout the healthcare continuum.
Coordination of services such as, transportation, referrals, and compliance. Assists families and patients through the healthcare system by acting as patient advocate and navigator connecting patients to relevant community resources with the goal of enhancing patient health and wellbeing.
Serve as point of contact, advocate and informational resource for family, patient, care team, school systems and their school nurses, community resources, and state agencies. Facilitates meetings/calls between patient /family, care team, payors, and outside agencies as needed.
Educates patient/family about a condition (existing or newly diagnosed) to assist them in appropriate self-management
Participates on a team for data collection, health outcomes reporting, clinical audits, and program evaluation related to the PCMH and Medical Neighborhood activities. Reports on Quality Improvement metrics/measures as needed for NCQA/PCMH/Nemours. Assists with the identification of areas for improvement within their practice.
Creates and promotes adherence to a care plan, developed in coordination with the patient/family, care management team and primary care provider.
Monitors specialty consults and follows up if patient/family did not follow through with the appointment or the consult report was not received by the PCP.
Contacts families with diagnostic testing results and advises next steps when needed.
Work with patient and family to facilitate access to the most appropriate care; reducing emergency room utilization and unplanned hospital admissions/readmissions.
Qualifications
BSN preferred, RN required. License eligible in DE
