Care Coordinator, Geriatric (Active LPN)

POSITION SUMMARY

Matrix Organizational structure with direct line to Geriatrics for population management outcomes and an indirect line to Director of GSL for completion of TOC and high risk patient management per policy and related nursing documentation.

REPORTING RELATIONSHIPS

This position reports to Director of Geriatric Service Line.

CARE COORDINATOR

• 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:
• Responsible for obtaining a 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
• Responsible for calling 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
• Responsible for arranging follow-up visits for transitional care patients with the GSL-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 scheduling for geriatrics
• Responsible for ADC pre-visit questionnaire completions and ensuring patients and caregivers are ready for the initial appointments
• Responsible for Health Risk Assessment completion prior to patient appointments for geriatrics
• Responsible for Caregiver Screenings
• 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:
• Responsible for running the high-risk stratification tool on a monthly basis, 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)
• Responsible for care coordination of at least 30 high risk patients and rising risk patients within the assigned panel (excludes patients managed by the GHP Care Manager)
• Responsible for obtaining and documenting 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
• Responsible for reviewing and documenting 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
• Responsible for assisting patients with self-management goal setting to improve healthy behaviors and manage chronic illnesses or conditions
• Responsible for billing the CC charges on a daily basis per procedure
• Responsible for timely referrals of patients with uncontrolled symptoms or unsafe functional problems to 1) the RN Manager, 2) the PCP, or 3) the Senior VP of Clinical Operations or Medical Director as directed
• Responsible for completion of all stat referrals (same day or next day)
• Responsible to manage at least 10 TOC cases at all times

MEDICATION MANAGEMENT

• Responsible for completing IV rehydration to patients as assigned
• Responsible for Home INR monitoring and Coumadin Safety Program as assigned
• Ensures that immunizations and medications are in stock
• Prepares and administers medications and injections as per physician or physician extender in absence of registered nurse

PATIENT CARE

• Responsible for timely referrals of patients with socioeconomic issues that interfere with treatment access, transportation, or patient safety to the social worker
• Responsible for doing lab draws, laboratory testing, and Point of Care testing and will observe, guide and direct Resident blood draws
• Responsible for the initiation and monitoring of insulin pumps per physician orders • Responsible for ambulatory Blood Pressure Monitoring applications
• Responsible for reading PPDs
• Responsible for triaging all panel patient calls and provides consultation in considerate and respectful manner
• Responsible for monitoring the closure of labs, diagnostic tests, referrals, and orders for panel patients
• Responsible for tracking and addressing partial labs and engage Residents to assist in
• Ensuring labs are addressed timely
• Responsible for observing, guiding and directing Resident blood draws
• Responsible for the completion of quarterly resident evaluations by patients, staff and physician preceptors to include several patient evaluations per Resident per month • Responsible for covering the care coordination of patients for other panels as needed when other Care Coordinators are absent
• Responsible for working with Wilkes University Pharmacy Program to ensure Residents are engaging with the pharmacist students for enhanced patient medication management • Responsible for working with GME Supervisor to ensure that adult and pediatric mock codes are held, using AED
• Responsible for completing all required and requested patient forms as needed • Responsible for assuring that all information that applies to the patient is documented in the EMR

LEADERSHIP AND QUALITY

• Responsible for Resident integration into clinical workflow
• Responsible for Resident orientation to clinic and ongoing engagement in sick line/medication refills, and work to streamline calls
• Responsible for oversight of the panel Quality Assurance Plan, PDSAs, and report distribution and sharing with Provider-Team
• Responsible for training new LPNs hired at the clinic and developing and maintaining the orientation plan and manual
• Responsible for the training of front office staff in management of patient questions and related clinical triage
• Responsible for exercising HIPAA confidentiality and security measures at all times during office hours and outside the office
• Responsible for demonstrating responsibility for self-learning through participation in continuing education activities and conferences
• Responsible for serving as clinical resource for staff, clients and families

OTHER FUNCTIONS AND RESPONSIBILITIES

• Perform all other duties as assigned

QUALIFICATIONS

• Licensed Practical Nurse with 3-5 years’ Long term Care OR Geriatric experience in healthcare environment
• Proficiency in Microsoft Word, Excel, and PowerPoint
• Previous experience in healthcare environment required (minimum 3-years)
• CPR Certification
• Interpersonal Skills
• Excellent verbal communication and congruent body language
• Effective telephone skills: checks messages frequently, returns phone calls promptly and uses professional telephone manners
• Customer service orientation: places the interests of the clients first and strives for customer satisfaction
• Maintain positive, professional office relationships
• Demonstrate responsibility for personal work habits and self-care
• Maintain positive client relationships
• Facilitation Skills
• Professional demeanor
• Maintain client confidentiality and professional standards as established by HIPAA
• Demonstrate appropriate knowledge of various required treatments