Education:  Current Michigan R.N., Nurse Practitioner, Physician Assistant or Master of Social

                   Work License.  Minimally, 2-5 years progressive experience in adult medicine in

                   primary care/ambulatory care, home health agency, skilled nursing facility, or

                   hospital medical-surgical setting, within the past five years.  Completion of self-

                   management support training.  Current BCLS certification.

Classification:  Full-time

Hours:  40 Hours per week

Accountability:             Physician

                                    Lead Care Manager

                                    Office Manager

Summary of Position: 

Provides care management and care coordination for adult and pediatric patients with complex health conditions, with complex social needs, with education needs and during the transition from hospital discharge to community (PCP, SNF, Home care, etc.).    Collaborates with Primary Care Physician, specialists, members of the health care team, patients/families to empower patients and to deliver quality, efficient and cost-effective health care services.  Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patent's health status and decreasing hospital readmission's.  Integrates evidence-based clinical guidelines, preventive guideline, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Responsibilities:

• Work with team to identify the targeted high risk population with the practice using the FPC Algorithm risk stratification tool and discharge lists.
• Collaborates with PCP, patient, and members of the care team, including continuum of care settings and community.
• Responsible for developing a comprehensive individualized care plan and targeted interventions. Continually monitors patient/family response to care plan, revises the care plan as indicated during the transition period (normally 30 days post discharge).
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
  • Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up:  medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care and problem solve barriers.
  • Maintain required documentation for all care management activities.
  • Works with hospital, practice and PO/PHO leadership to continuously evaluate process, identity problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
  • Continue education regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.  Serves as liaison to acute care hospitals, specialists and post-acute care services.

Additional Responsibilities

Demonstrate patient focused interpersonal skills to interact in effective manner with practitioners, the health care team, community agencies, patients, and families of diverse opinions, values, and religious and cultural ideals.

Demonstrate ability to work autonomously

Demonstrate ability to influence and negotiate individual and group decision making.

Demonstrate ability to function effectively in a fluid, dynamic, and rapidly chang