Chronic Care RN (Support Coordinator)

Collaborates with practice staff in identifying appropriate patients for chronic care 
management.
? Formulates and implements a chronic care management plan that addresses the patient's
identified needs by assessing the patient/family needs, issues, resources and care goals; 
determining the choices available to individual patients; educating the patient/family on the 
choices available.
? Establishes a chronic care management plan that is mutually agreed upon by the health care 
team and the patient/family. Plans will contain specific mutual self-management goals, 
objectives, and interventions with the patients are action-oriented.
? Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as 
needed to reflect changing needs, issues and goals. Collaborates with the healthcare team when 
changes occur. Monitors and evaluates the progress of the patient. Initiates care conferences to 
discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
? Identifies and effectively utilizes community resources to meet the needs of patients/families.
? Promotes patient self-management and empowers patients/families to achieve maximum levels 
of wellness and independence. 
? Interacts professionally with patient/family and involves patient/family in the formation of plan 
of care.
? Maintains regular, ongoing contact with clients, caregivers, specialists and service providers
through home visits and phone calls.
? Manages care transitions, which may include home visits, including providing referrals and 
facilitating follow-ups for the patient upon discharge from medical facility. Performs 
medication reconciliation for all care transitions. 
? Provides coverage across HBPC as needed. This may include clinicaltasks . 
? Participates in community health activities.
? Participates in regular team meetings, peer review activities, and quality and organizational 
committees. 
? Participates in the orientation of new personnel. Precepts and mentors peers. Promotes 
collaborative teamwork.
? Abides by the organization's compliance program and requirements.
? Works collaboratively with leadership team to improve and enhance care delivery through the 
 evaluation, development and enhancement of policy and procedures.