JOB SUMMARY:

As a member of the Community Health Team, the Nurse Care Coordinator works with patients to identify their health goals and together with their practitioners create a care plan that will support them in achieving their goals. The Nurse Care Coordinator provides healthy lifestyle counseling, education for chronic conditions, and general care coordination for high-risk, socially and medically complex patients. This role helps identify and manage unmet needs of the patients to ensure appropriate resources are in place to improve health outcomes.

1. FUNCTIONS and RESPONSIBILITIES

1. Provides patient and family education and instruction on issues of health maintenance and management of chronic conditions, provides patients/families with educational materials for self-management that are both paper and web-based.

1. Will perform duties within scope of practice per license and follow standards of practice as outlined by, but not exclusive to:

1. Vermont State Board of Nursing for Registered Nurses and Licensed Practical Nurses;

1. The Commission on Dietetic Registration for Registered Dietitians;

1. The American Association of Diabetes Educators and the National Certification Board for Diabetes Educators for diabetes educators.

1. Will keep up to date on the current standards and best practice recommendations as outlined by the respective governing board.

1. Coordinates patient care with members of the integrated health care team.

1. May use reports or reporting systems to identify high-risk patient populations.

1. Collaborates with cross-departmental teams and/or members of partner agencies to develop care plans.

1. Actively participate in multiorganizational care teams and case reviews to provide patients with wrap-around care coordination through diverse community resources.

1. Be a clinical resource to non-clinical members of the care team.

1. May use electronic communication to communicate about patient needs with members of the CHT and other appropriate agencies following all organization and HIPAA policies and procedures to improve care coordination.

1. Will use a patient-centered approach, including motivational interviewing, on developing care plan.

1. Provides care coordination for medically and socially complex patients.

1. Meets with patients to assess and identify any unmet health needs.

1. Connects patients to community supports.

1. Works closely with health care practitioner to develop plan of care.