• Collaborates with physician and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.

• Conducts initial and periodic holistic assessments for care managed population.  Prioritizes patients according to intensity, need, and required follow up.

• Formulates and implements a care management plan that addresses the patient’s identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; and educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the health care team and patient/family.  Evaluates the effectiveness of the plan in meeting established care goals, and revises the plan as needed to reflect changing needs, issues, and goals.

• Identifies and effectively utilizes community resources to meet the needs of patients and families.

• Promotes patient self management and empowers patients/ families to achieve maximum levels of wellness and independence.

• Assists the patient to identify and/or develop their support system and encourages the patient to utilize their support system.

• Collaborates with physicians, other healthcare team members including inpatients facilities, the patient’s payer, and health system administrators to facilitate care across the healthcare continuum and optimize clinical and financial outcomes.  Determines and completes appropriate referrals.  Serves as a liaison to providers, patients, and families for coordination of services.

• Maintains a working knowledge of payer requirements.  Develops collaborative working relationship with insurance case managers; negotiates on behalf of patient with third parties for cost-effective, high quality services to maximize the efficient use of resources.

• Maintains databases on care managed population.  Maintains accurate and timely documentation

• To promote wellness, improved outcomes and self care within a defined population of members with a long term condition(s) complex health needs and support their appropriate utilization of health services

• To work with individual patient and providers of care to develop and implement individual health plans and provide support to the member in self management.  Member is defined as a patient with one or a number of long term conditions that are referred into the health home.

• To undertake the assessment, planning, implementation, coordination and review of health plans and encourage the appropriate utilization of series to me art risk members complex health needs.  This will be achieved through proactive telephone communication using health behavior change coaching, facilitated by decision support software and the co-ordination of available healthcare resources.

• Promoting care management with a philosophy of enabling and promoting self care, self management and independence.

• The post holder will be responsible for the supervision, coaching, teaching, precepting and mentoring of associate care managers, health coaches and other staff and/or students.

• Meet and assess clients upon referral

• Work with doctors, nurses, dentists, psychiatrists, and social workers to develop the best plan of care for the patient and monitor implementation of the plan and progress of client and adjust plan as required.

• Visit patients face to face regularly (weekly preferred at minimum monthly) supplement with volunteers and other correspondence.

• Attend patient’s interdisciplinary planning meetings

• Make medical decisions for patients as need arises and consult doctors and those who work closely with patient in order to make the best possible decision for the patient

• Build relationships with other  agencies who serve the health home patients

• Provide care management services to assist patients in receiving necessary resources and services.  Medicaid, Child Health Plus, Welfare, DAS, Social Security, Child Care, Home Care, Housing/Shelter/Safe Homes, Substance Abuse Treatment, Mental Health Treatment, HIV and mental health services

• Work with providers to assess child abuse and neglect and follow guidelines for reporting when necessary; provide follow-up support services to families to maximize family functioning.

• Document all patient services in patient’s electronic medical record, closes encounters within 48 hours.

• Provides monthly statistical reports to administration.

• Participates in all required staff meetings.

• Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patients served in assigned area.

 Not Applicable

• Complies with accepted dress code and maintains a professional image.

• Maintain a professional image

• Participate in department performance improvement activities

• Demonstrates flexibility in the acceptance and completion of work assignments.

• Manages time and resources to meet established goals in agreed upon time frame

• Demonstrates reliability and trustworthiness

• Submits leave request in a timely fashion

• Adheres to Policies regarding time and attendance

• Assists in preparation for site visits by funders or regulatory agencies

• Adheres to agency Policies on conduct, harassment and violence in work place

• Follows and enforces agency Policies surrounding work place violence and sexual harassment

• Participates in the development of other staff members.

• Meets regulatory, and annual health assessment requirements.

• Identifies learning strengths and needs

• Utilizes learning resources.

• Demonstrates a professional, courteous, and respectful attitude with patients, families and significant others.

• Demonstrates a professional, courteous and respectful attitude with clinical practice staff.

1. E.    Documentation Section

• Enter all encounters into electronic medical record system

• Ensures all patients are “arrived” in electronic medical record system

• Completes  assessment on all new patients on first visit or documents when unable to do so

• Accurately records level of service in electronic medical record system

• Documents all referral services

• Obtains patient consents to coordinate with all referrals and services

• Accurately completes patient logs, flags patients with chronic illness in electronic medical record, puts “FYI” in chart as appropriate

• Completes statistical data in a comprehensive and timely manner

• Follows agency and funder guidelines for outreach and documentation of outreach

• Provides feedback to primary care providers and the health care team as appropriate

• Closes all patient care encounters within 48 hours

• Responds to all referral requests within 48 hours

• Provide health education information and resources and documents in patient records

• Appropriately refers patients for mental health services

• Appropriately advocates for patients with outside systems and service providers,

• Participates in the provision of group services to patients with chronic illness, coordinates and co-facilitate as requested/required

• Has an understanding of chronic medical illness such as Diabetes, HIV, Depression

• Collaborates with agency staff in the care delivery to patients and their families around the care of chronic illness

• Identifies service gaps and seeks solutions, both within the organization and outside in the community and creates outside linkages to address care management needs of patients with chronic illness. Identifies and utilizes community resources in the provision of care management

• Actively utilizes quantitative measures to monitor patient progress such as A1C, PHQ9 , blood pressure, weight and documents progress in patients record and discusses with patient , collaborates with patient and care team to improve measures and outcomes. Reinforces SMART goals with patients and utilize SMART in development of plans with patients

• Conducts individual care management sessions utilizing evidence based and best practice strategies including behavioral activation, harm reduction, problem solving treatment and related treatments to assist patients and improve health outcomes

• Meets agency and funder visit targets

• Creatively approaches outreach and care management for patients who are hard to engage or lost to follow up or care for a chronic illness, follows up with patients who were recently discharged from the hospital, participates in discharge care planning

• Notifies supervisor of all home and off site patient visits and follows organizational polices for home visits, collaborates with diabetes educators and other providers on home visiting

• Proactively works with patients and care team to provide care management services

• Treats patients with respect

• Is empathic and understands the difficulty of coping and living with chronic illnesses

• Engages patients into care, proactively

• Appropriate refers patients to pharmacy programs.

• Utilizes educational materials, videos and information to provide care management services to patients in an appropriate format and a format mutually developed with patients