Population Health Nurse

The CCM Population Health Nurse, performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. They work in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making.

Job Description:

· Establish and maintain trust relationship with CCM program patients and team members

· Perform initial nursing assessment and needs assessment on new referrals to the CCM program. Collect key information from chart and other team members prior to initial assessment.

· Develop care plan with other team members. Determine priorities for interventions.

· Provide ongoing monitoring and assessment with CCM patients, especially at points of transition from inpatient setting, visits with specialists, medication adjustments.

· Assists patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).

· Performing and/or overseeing all care coordination duties necessary to successfully implement plan of care.

· Acts as the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns. May assume advocate role on the patients behalf with the carrier to ensure approval of the necessary supplies/services for the patient in a timely fashion.

· Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers.

· Remind, or delegate task and ensure it was completed. Scheduling of patient appointments via mail or phone.

· Maintain ongoing electronic tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety.

· Organizes documents and arranges team meetings for CCM patients.

· Ongoing phone follow-up of CCM patients, scheduling as identified in care plan, unscheduled as needed to ensure care plan is being followed.

· Ensure that patient’s primary care chart is up to date with information on specialist consults, hospitalizations, ER visits and community organization related to their health.

· Assists with any other duties as assigned.