This role is an invaluable part of Beacon Health’s population health efforts. We believe that patient environments have both supports and barriers which significantly impact their health. This RN position works in close collaboration with the practice team to provide home/environmental/social assessment to the team for consideration in care planning. This RN promotes good health by working closely with the patient to limit the impact of environmental and social barriers and strengthen their supports in an effort to achieve better outcomes. This position is an extension of Beacon Health’s practice based RN Care Coordination services. Oversees clinical care to patients with chronic disease, high cost of care, and/or less than ideal access to traditional outpatient medical services. Collaborates with the Medical Team and relevant community based supports to provide a model of care that ensures the delivery of quality, efficient, and cost effective healthcare services. Integrates evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Utilizes evidence based shared decision making models and motivational interviewing to encourage positive behavior change. Completes home/community visits. Reports to: Community Care Team Program Manager.
Manage utilization and practice metrics to refine the delivery of care model to maximize clinical, quality and fiscal outcomes for the population
Monitor patient progress and promote early intervention in acute care situations
Provide safe transition of care across the continuum of care
Promote and convene communication among all service providers on behalf of and with the patient
Provide patient education, related to chronic disease management, home safety
Promote patient independence, safety and self-management
Demonstrate autonomy being accountable for their practice
Demonstrate the ability to negotiate and influence individual and group decision- making.
Adapt to a fluid, dynamic and rapidly changing environment.
Demonstrate leadership qualities in the areas of time management, problem solving, decision making, priority setting, delegation, organization, written/verbal communication and listening skills.
Implement monitoring systems for high-risk member to prevent and/or intervene early during acute exacerbations.
Works with the primary care practice team to ensure appropriate standing orders for acute exacerbation management (such as diuretic titration protocol).
Continuously evaluates all available patient information including, laboratory results, diagnostic tests, utilization patterns and other metrics to determine barriers to improved care, improved quality, and decreased cost. Provides regular progress updates to members of the care team.
Collaborates with providers, including community based organizations, to ensure smooth process in place when movement between settings occurs.
Provides home and community visits.
SKILLS AND ABILITIES:
Needs to be professional as well as knowledgeable, responsible, and accountable to provide patient care over the continuum and to assist in improving quality, cost, and patient/service satisfaction outcomes.
Will be responsible for assessment, planning and implementation process for a select group of patients in the outpatient setting.
Must be organized with the ability to self-motivate and prioritize a
variety of duties.
Proficient in computer literacy including but not limited to the electronic medical record, electronic data entry, retrieval and report generation.
Ability to work effectively with clinical and non-clinical staff and community organizations
Understanding of community services and how to access them.
Must have willingness to learn about and work with people who have behavioral health and substance abuse disorders.
Demonstrated ability to work with an interdisciplinary team.
Demonstrates excellent communication skills.
Demonstrates the ability to perform multiple tasks simultaneously.
Ability to motivate others
Ability to work with people from diverse backgrounds and experiences
Ability to openly address and acknowledge observed issues and concerns
Must pass background check.
Demonstrates proficiency in basic computer skills, including accurate keyboard entry of data into relevant computer based databases and spreadsheets,
Attention to detail, and ability to be flexible in performing a variety of tasks.
Demonstrated ability to complete projects within designated timelines and the ability to prioritize duties is required.
Demonstrates proficiency with Microsoft Word and Windows & Excel, and the ability to learn various system software.
Demonstrates ability to use basic office equipment, computer, fax machine, copier, calculator, etc.
EDUCATION AND/OR EXPERIENCE:
Registered Nurse with three to five years of recent (within the last 3 years) acute care experience or relevant experience required.
Licensed at an RN level by the State of Maine Board of Nursing.
Bachelor’s degree in Nursing preferred
Experience in home health nursing preferred.
Knowledge of the basic principles of care management and care coordination required.
Valid Maine driver’s license.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Employee is exposed to environmental factors such as dust, fumes, temperature, humidity, heights, machinery, driving.
Other duties or comments specific to this position: Expected to drive on a wide range of roads and in inclement weather.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.