LPN Care Coordinator, Geriatric

Description

POSITION SUMMARY

The Geriatric LPN Care Coordinator serves as a liaison between the patient and the providers. Geriatric LPN Care Coordinators are responsible to perform regular updates on patient well-being, help develop treatment plans, communicate with patients about their diagnoses and care plan, evaluate the patient’s recovery process. Geriatric Care Coordinators ensure that patients have access to medical resources. Their primary goal is to improve patient outcomes by ensuring that patients understand their condition and treatment plan.

REPORTING RELATIONSHIPS

This position reports to the Director of Geriatric Service Line . The position works directly with clinical staff, residents, physicians, providers and practice managers.

DUTIES & ESSENTIAL JOB FUNCTIONS

• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that have experienced any transition from a healthcare facility (i.e. ED, hospital, rehabilitation facility, SNF, etc.) to home including follow-up phone calls and the coordination of follow-up visits with the primary care Provider-Team to include:
  • Obtaining daily list of patients admitted and discharged from the hospital, using My Patient Your Patient Software, and meeting with GHP Case Manager to determine accountability for patient TOC management. If the GHP Case Manager is absent, the LPN CC is responsible for completion of all TOC calls and related patient management and for communicating daily with the GHP Case Manager replacement to review TOC data for GHP and Medicare fee for service patients
  • Call assigned transitional care patients within 48 hours of discharge to collect and document information and data from the patients about symptoms, functional status, safety, and support at home, current complaint/s, and medication reconciliation
  • Arrange follow-up visits for transitional care patients with the Primary Care Provider-Team within 2-7 days post discharge based on patient needs (within 2-3 days if symptoms not managed, functional status concerns, safety issues, no support at home, medication non-reconciliation)
• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that are medium risk, rising risk or high risk and Rising Risk Registry of Patients to include:
  • Run the high-risk stratification tool monthly, reviewing the list with the lead panel Provider to identify/verify the list high risk panel patients, and then adding high risk patients to Care Coordinators’ high-risk registry (list excludes patients managed by GHP Case Manager)
  • Coordinate care of at least 30 high risk patients and rising risk patients within the assigned panel (excludes patients managed by the GHP Care Manager)
  • Obtain and document information and data from the patients about vital signs, symptoms, functional status, safety and support at home, socioeconomic status, current complaint/s, and medication reconciliation
  • Review and document the education plan with patients to include use TWC-specific handouts that address basic disease information, symptom management, functional status concerns, safety issues, and medication information and administration information
  • Assist patients with self-management goal setting to improve healthy behaviors and manage chronic illnesses or conditions
• Bill the CC charges daily per procedure
• Facilitate the weekly Huddle at MVP
• Attend monthly ACO meetings
• Manage allotted TOC cases
• Cross coverage of other locations and service lines for continued support and access for patients
• Participation in extended access hours including late nights, weekends and holidays
• Understanding of multiple insurance dynamics including copays, coverage, navigation to assist the patient with medication or services
• Commitment of outreach and engaging a minimal of 30 patients per month who are enrolled in TWCCH’s Chronic Care Management Program
• Daily reconciliation on hospital admissions and discharges for high risk patients for timely coordination of next steps to prevent readmission, crisis, and to keep care team up to date on patient status
• Maintaining required certifications and training to be compliant with the HRSA credentialing regulations.
• Completing and staying up to date on yearly competencies for hands on skills
• Coordinate timely referrals of patients with socioeconomic issues that interfere with treatment access, transportation, or patient safety to the social worker
• Conduct ambulatory Blood Pressure Monitoring applications
• Conduct reading PPDs
• Triage all panel patient calls and provide consultation in considerate and respectful manner
• Monitor the closure of labs, diagnostic tests, referrals, and orders for panel patients
• Cover the care coordination of patients for other panels as needed when other Care Coordinators are absent
• Partner with GME Supervisor to ensure that adult and pediatric mock codes are held, using AED
• Complete all required and requested patient forms as needed
• Ensure that all information that applies to the patient is documented in the EMR
• Oversee the panel Quality Assurance Plan, PDSAs, and report distribution and sharing with Provider-Team
• Exercise HIPAA confidentiality and security measures always during office hours and outside the office
• Demonstrate responsibility for self-learning through participation in continuing education activities and conferences
• Serve as clinical resource for staff, clients and families
• Understanding of what it means to be the following:
• A Federally Qualified Healthcare Center Look - Alike (FQLA)
• A Patient Centered Medical Home (PCMH)
• Recognized as a National Committee for Quality Assurance (NCQA)
• Participant in an Accountable Care Organization (ACO)
• Ensure patients understand health center resources and available programs, such as
  • Sliding fee discount program
  • Good Faith Estimate (GFE)
  • Outreach & Enrollment programs
  • Language services
  • After hours coverage

Requirements

REQUIRED QUALIFICATIONS

• Meet The Wright Center for Community Health and its affiliated Enterprise entities’ EOS People Analyzer Tool
• Buy in and experience working in the EOS® model (strongly preferred)
• Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride
• Graduate of an accredited LPN program
• Active Pennsylvania Practical Nursing license
• Previous experience in a health center setting a plus
• BLS Certification
• Experience with electronic health record, Medent a plus
• Ability to work as part of a care team
• Excellent communication skills
• Commitment to process improvement and quality