Care Coordinator- Orthopedics Lorain, CCHS Employees Only Job
Date: Jul 29, 2014
Location: Lorain, OH, US
CCHS Employees Only
HR Use Only: Care Coordinator- Orthopedics Lorain
Hospital: Main Campus Exempt
Facility: Lorain Family Hlth Surgery Ctr
Department: Lorain Orthopaedics
Job Code: T99128
Pay Grade: 13
Schedule: Full Time
Please note: This position will require travel to Lorain ASC, Avon ASC and Lakewood Hospital as well as some office hours.
Works collaboratively with multidisciplinary care team staff across the continuum of care to provide care and disease management to high risk patients identified in the ambulatory setting, focusing 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.In Specialty Care areas: Patient Identification - Identifies which patients in the specialty 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 Identifies the primary care team involved in the specialty patient care. In Primary Care areas: Patient Identification - Uses 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, etc.) to ensure timely and efficient care delivery across the continuum of care. Utilizes technological tools (registries, patient lists, etc.) to manage populations. Assessment - Conducts comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient. Actively involves the patient and family regarding coordination of their care. Shares this information with the healthcare team, patient, and family. 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. Coordination - Often serves as primary patient contact for team related to condition; facilitates access to services. Links members of the patient care team. Organizes tasks and responsibilities around the patient and family needs. Serves as the liaison with patients and families to physicians, clinical staff. Assists in managing transitions of care across care settings, ensuring optimal communication and planning between care providers across different settings. Identifies barriers to receiving care and facilitates solutions. Connects patient back to primary care physician and primary care coordinator team as applicable. Liaison with other partner care coordinator teams across settings (e.g. transitional care). Partners with other care coordinator teams (e.g. primary and transitional care). Team includes Social Work, Rehabilitation, Pharmacy, Palliative Care and others. Defines and ensures compliance with disease-specific care paths for specialty care or chronic disease. Education/Advocacy - Advocates for patient and families, responds to and facilitates resolution of patient/family questions and concerns. 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 (including acute exacerbation management). Education about managing a specialty condition, including prevention and health maintenance tasks. Education and connection to other care providers and community resources to enhance care. Quality Improvement - Works with practices on quality and process improvement initiatives. Assists in education, auditing quality, data analysis, and workflow processes. Outcome metrics include (but are not limited to) patient satisfaction, readmissions, cost per case, and compliance with care paths or evidencebased guidelines. Other duties as assigned.
EDUCATION: Graduate of an Accredited School of Nursing; BSN required within five years of start date if hired after 4/1/2014 for all external hires and voluntary internal transfers.
LICENSURE/CERTIFICATION/REGISTRATION: Current state licensure as a Registered Nurse (RN). Specialty certification preferred. Basic Cardiac Life Support (BLS) required. 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.
REQUIRED EXPERIENCE: Three to five years of nursing experience required. Strong orthopaedic surgical background and ability to scrub primary total joints.
PHYSICAL REQUIREMENTS: 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 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: Follows Standard Precautions using personal protective equipment as required for procedures. MEDICAL STAFF APPROVAL:
Nearest Major Market: Cleveland
Nearest Secondary Market: Akron
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