Leadership and development of care coordination services across locations and settings (acute care, primary care, emergency services, community sites) Development and implementation of care coordination model in accordance with FQHC, PCMH, Blueprint for Health and ACO standards, values and models Support and model care coordination services, including direct delivery as needed and appropriate.
Care Coordination/Case Management/Transition Management experience required; Experience working in a supervisory/leadership role required.
Experience working with Patient Centered Medical Homes strongly preferred; knowledge or experience with population health service models preferred.
Bachelors degree or equivalent professional training required (BA, RN, BS). Masters preferred (MSN, MSW, MPH, MA).
Several years experience in providing care coordination/care management/case management services and experience in a supervisory/leadership role. Understanding of health systems, quality improvement and program evaluation, and patient-centered medical home model of care essential.
Must be able to plan, organize, and prioritize multiple activities and maintain positive relations with a wide variety of people and work collaboratively with all stakeholders. Flexibility is a critical skill. Must have an awareness of and sensitivity to the cultural diversity of the population served. Ability to maintain a non-judgmental disposition and communicate with a diverse population Effective verbal and written communication. Knowledge of community resources. Desire and ability to work closely with low-income population
1. Leadership and development of care coordination services across locations and settings (acute care, primary care, emergency services, community sites)
Develop a positive culture to promote continuous growth and staff development
Provide supervision and mentorship to Care Coordinators. Oversee, monitor and develop the performance needs of assigned personnel.
Participates in quality improvement projects and activities including the design and implementation of PDSAs, data reviews and learning collaboratives
Provides clinical and community resources for care management team to ensure high quality, coordinated services are delivered appropriately
Serves as a resource to staff on all training and continuing education and client wellness activities and education and develops and coordinates programming in response to the needs of management; staff; clients; and of specific sites.
Establish and maintain relationships with community service providers. Serve as a resource to staff on how to coordinate client access to services.
2. Development and implementation of care coordination model in accordance with FQHC, PCMH, Blueprint for Health and ACO standards, values and models
Serve as the local content expert on the care coordination program, including resources and supports available to support adoption;
Serve as the point person for communication between local care coordination teams and the OneCare care coordination team, including the HSA-assigned Clinical Consultant;
Provide project management support by participating in monthly Care Coordination Core Team meetings facilitated by OneCare, and other cross-sector meetings as needed; suggest and/or facilitate active work sessions at Core Team meetings as appropriate; facilitate and support regular HSA-level Core Team meetings and projects to ensure effective implementation and refinements to the care coordination program;
Facilitate development of community-specific care coordination workflows, including mapping key components of the care coordination model (i.e., identifying people using OneCare data tools, engaging individuals, identifying lead care coordinators, establishing person-directed goals, developing and maintaining shared care plans, and mapping flow between community organizations) and financial models (i.e., flow of care coordination funds between organizations);
Refine and evaluate community-specific care coordination workflows, including mapping key components of the care coordination model, for two targeted projects, subpopulations (i.e. age, gender, or condition-specific) or organizations;
Monitor and promote engagement of high and very high risk individuals across payer programs; work to engage at least 15% of eligible individuals in active care coordination;
Review monthly HSA data reports; identify strengths and areas of opportunity; develop and implement strategies to address identified opportunities;
Identify and communicate to the OneCare care coordination team any barriers to successful implementation of the care coordination model, care coordination skills or software trainings, and/or community partner and practice engagement; and Actively solicit ideas from HSA partners for enhancements to the care coordination program, including the financial model, software, training, and evaluation of impact and achievements; share ideas and lessons learned with OneCare care coordination team to facilitate continuous performance improvement; work with other designated Project Managers to share insights and lessons learned.
3. Support and model care coordination services, including direct delivery as needed and appropriate
Actively coordinate care on behalf of patient as indicated Collaboratively support safe and timely transitions of care to include: timely medication reconciliation, communication with providers, and ensuring the individual's understanding of discharge instructions, referrals and care plans c.
Participate in care conferences or care team meetings
Assess need for and facilitate engagement in palliative and hospice care as needed
Utilize Care Navigator for timely and accurate recording and communication of key care coordination activities
Actively participate in the design and refinement of community-specific workflows and care coordination work plans by participating in and/or providing input to local meetings, planning events and learning collaboratives.
Participate in local care coordination trainings and competency assessments.
Maintain necessary knowledge and skills to conduct effective patient-centered care coordination activities.
Monitor patient panels, conduct gap analyses and identify opportunities for performance improvement.