LPN/LVN Chronic Care Management

The LPN provides patient centered nursing care. Obtains vital signs, gathers pertinent health information while following decision trees and protocols. Provides triage and consultation to patient, family, and/or significant others according to protocol and
established guidelines. Involves family in plan of care implementation. Recognizes significant changes in patient’s condition, status, and need for care. Provides ongoing assessment of patient and takes appropriate action when changes occur. Coordinates with other health care team members to give patient centered care. The LPN provides status updates to physicians and supervising nurses on a regular basis. Documents, maintains and updates accurate patient records according to agency, state, and federal guidelines. Administers medications under physician orders. Monitors the patient’s medication needs and response to treatment. Performs laboratory procedures and assists the physician/provider with procedures and surgeries using principles of aseptic technique and standard precautions/infection control guidelines. LPNs facilitate communication between
patients and the physician by receiving messages and responding to them on behalf of the physician. They also help inform the patient of results of diagnostic studies and educate patients regarding plan of care. They will also participate in department activities related to quality improvement. Performs other tasks as assigned.

• Communicate with and educate patients about plan of care, medications, diagnostic study results, and return general messages.
• Monitor the patient throughout the course of care. Communicate and document the results of these evaluations thoroughly.
• Assist with patient exams and treatments.
• Administer medications following the rights of medication administration. Monitor the patient for reactions, side effects, andeffectiveness of treatment.
• Participate in quality improvement activities within the department.

Values
i - Innovation
"Think Forward" "Set Out-Of-The Box Goals" "Exploring new possibilities" I am the change agent that advocates for our customers. I think outside of the box to create Exceptional experiences that set us apart. I look for solutions and think of new ways to solve problems, even if it is outside of my department.

C - Compassion
"Demonstrate genuine concern" "Display a Selfless attitude" I show kindness in every interaction. I strive to build trust with our co-workers and customers. I will communicate with our co-workers and customers in a way they understand. I will make time to address our co-workers and customers' needs.

A - Accountability
"Show integrity" "Accept Ownership & Responsibility" I will demonstrate integrity by doing the right thing, being honest and having strong moral principles. When mistakes occur, I take the necessary steps to correct them, without dismissing patient concerns and follow through until resolution. I fully document actions taken to ensure continuity of care. I communicate expectations and follow up within defined time frames and provide updates as I understand them for my customers and teammates.

R - Respect
"We value diversity" "Respect is earned" I treat all people with dignity and respect, regardless of their beliefs. I do not use negative/derogatory language. I accept constructive feedback and suggestions for the greater good.

E - Empowerment
"Share Knowledge" "Take Action" I will share knowledge to empower others and encourage them to make informed decisions. I encourage others to reach their full potential. I will encourage trying new things, diverse ideas, and learning from our mistakes. I have the freedom to do what is right for our customers.

ORGANIZATION EXPECTATIONS:

Communication

The process of sending and receiving messages with words, verbally, written or in sign language.

Customer Focus

Identifying and responding to current and future patient and other customers’ needs; providing excellent service to internal and external patients and other customers.

Initiative

Identifying and dealing with issues proactively and persistently; seizing opportunities that arise.

Self-Development

Lifelong, voluntary, and self-motivated learning.

Teamwork

Effectively work and complete assignments in group settings. Works independently and cooperatively with others to achieve common goals.

Essential Functions

• Develop, conduct, or coordinate health needs assessments and other public health surveys.
• Develop and maintain cooperative working relationships with agencies and organizations interested in public health care.
• Design and conduct evaluations and diagnostic studies to assess the quality and performance of health education programs.
• Appraises his/her performance to identify areas of strength and areas for improvement and to develop a plan for improvement and growth.

Experience

3-5 years experience in a clinical or community health setting preferred.

Previous experience in caring for chronic disease patients required.

Previous care coordination, case management or home health experience preferred.

Previous experience with health IT systems and data reports preferred

Education

LPN/LVN Licensure Required

If you are a current employee or have previously worked for Nor-Lea Hospital District, please contact the Human Resources Department at hrgroup@nlgh.org for your correct username and password.

ACO

Chronic Care Management LPN/LVN

Chronic Care Management (CCM) roles focus on coordination, ongoing support for patients with two or more chronic conditions, ensuring care plans are followed, services are accessible, and quality outcomes are maintained. Conduct monthly counseling/education for disease management, self-care, and medication adherence. Monitor adherence to care plans, evaluate effectiveness and adjust as needed. Coordinate with Primary Care, specialists and community resources; facilitate referrals and transitions of care.