Location: North Country Primary Care

Position: RN Patient Care Coordinator

Primary Functions:

Our mission is to provide patients with the highest possible quality of healthcare within an atmosphere of genuine caring. This includes recognition of the importance of quality customer service to patients, visitors and staff. Each nurse has the following responsibilities:

Works independently in a safe and appropriate manner.

Displays sensitivity and empathy to the needs of patients, visitors and staff.

Recognizes time as a most valuable resource and responds promptly to patients, visitors and staff.

Works carefully and precisely with attention to detail.

Prioritizes delivery of care and utilizes resources to maximize efficiency.

Meets requirements of position.

Able to evaluate/implement changes to meet patient needs.

Summary of Major Function: Registered Nurses are responsible for the delivery of safe, timely, appropriate patient care through the use of nursing process. The Registered Nurse understands and adheres to all hospital and department specific policies and procedures as well as to the practice standards set forth in the New Hampshire Nurse Practice Act. The Registered Nurse retains the responsibility for the direction and guidance of ancillary personnel activities within the units. The Registered Nurse provides individualized care, education and support which addresses the immediate and anticipated needs of the patient and family across the care continuum. Review of individual job descriptions with employees is an on-going part of our annual performance evaluation program.

The Registered Nurse coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. The Registered Nurse facilitates a "shared goal model" within and across settings to achieve coordinated high-quality care that is patient and family-centered.

Patient Care: 

The nursing process is utilized to provide comprehensive, age appropriate nursing assessment including biophysical, psychological, social and educational needs.

Assessment of patients learning needs, abilities, preferences and readiness to learn with consideration to cultural and religious practices, emotional barriers and financial implications of care choices.

Patient assessment and interview is utilized to formulate an individual care plan within the limits of New Hampshire Nurse Practice Act and Littleton Regional Hospital policies and procedures.

Patient and family involvement in development of the plan of care and all care decisions will be a priority.

Implementation of all clinical and technical aspects of individual patient care plan to include the use of proper techniques, infection control guidelines, established procedures/safety precautions to meet the individual needs/priorities of the patient.

Supports and augments the medical regimen by implementation of physician orders.

Provides accurate and timely documentation of nursing interventions, patient response, and nursing evaluation and further actions if required.

Evaluate: Reviews and evaluates patient care plan through continuous patient assessment. The plan of care is coordinated in consultation with multidisciplinary team involvement and adjusted to provide seamless delivery of care across the patient care continuum.

Ongoing evaluation of patient care will include continued patient/family involvement and adjustment to meet the evolving biophysical, psychological, social and educational needs.

Professional Conduct:

Supports and contributes to the Mission and Vision of Littleton Regional Hospital with a continuous focus on excellence in customer service and patient care delivery. Establishes and maintains a professional relationship with patients, visitors, staff, physicians and the community.

Adheres to hospital, departmental, and compliance policies, procedures, regulations, and laws (OSHA, DEA, CLIA, etc)

Assures confidentiality of patient information at all times.

Performs other duties as needed within the scope of practice in support of departmental and institutional needs and requirements Provides telephone triage

Assists/chaperones the treatment of patients in accordance with policy, procedures and guidelines

Duties and Responsibilities:

Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.

Implement an effective internal tracking system for identified patients.

Coach patients/families toward successful self-management of their chronic disease.

Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.

Assess patient and family's unmet health and social needs.

Provide effective communications to improve health literacy.

Develop a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate.

Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.

Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time. Promote healthy behaviors in all populations and ensure navigation assistance with community resources.

Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).

Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.

Serve as the contact resource, advocate and informational resource for patient, family, care team, payers, and community resources. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments and patient outcomes. Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records).

Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.

Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach Certification, quarterly Regional Workshops, monthly cohort calls with other NRACO Care Coordinators and Coaches).

Position Competencies: 

Core values consistent with a patient/family-centered approach to care.

Demonstrates professional and effective written and verbal communication skills.

Demonstrates a positive, respectful attitude and professional customer service.

Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.

Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.

Recognizes and responds to opportunities for improvement.

Demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice. Demonstrates professional practice behavior.

Provides mentoring/coaching of other population health and care coordination team members.

Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).

Demonstrates understanding in use of IT resources and patient databases.

Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

Physical Environment: Exposed to all patient elements including exposure to human waste. At times, long and irregular hours are necessary. Exposure to hazardous substances is, at times, unavoidable. Frequently, multiple tasks and patient needs must be addressed in a rapid fashion with prioritizing life-threatening situations and organization of the remainder of the needs.

Education: 

Must be currently licensed or eligible for licensure as a Registered Nurse in New Hampshire.

Must be a graduate of an accredited school of nursing

Bachelor of Science preferred

Experience: 

Previous experience in caring for chronic disease patients required. 3-5 years experience in clinical or community health settings preferred.

Previous Care Coordination, Case Management or Home Health experience preferred.

Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.

Proficient in communication technologies (email, cell phone, etc.).

Must have ability to communicate compassionately with patients, families, visitors and office staff

Must possess the ability to interact well with people and deal with stressful situations appropriately.

Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.

Effective organizational skills and demonstrates ability to maintain accurate notes and records-excellent documentation skills.

Previous experience with health IT systems and data reports preferred.

Must have ability to understand medical records, provider's orders

Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.

Ability to speak a relevant second language preferred.

Must be flexible and able to work as member of the team.

Basic Cardiac Life Support Certification

All staff will be required to float, when needed, within the parameters of orientation and hospital policy

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Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.