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- FUNCTIONS and RESPONSIBILITIES
- 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.
- Will perform duties within scope of practice per license and follow standards of practice as outlined by, but not exclusive to:
- Vermont State Board of Nursing for Registered Nurses and Licensed Practical Nurses;
- The Commission on Dietetic Registration for Registered Dietitians;
- The American Association of Diabetes Educators and the National Certification Board for Diabetes Educators for diabetes educators.
- Will keep up to date on the current standards and best practice recommendations as outlined by the respective governing board.
- Coordinates patient care with members of the integrated health care team.
- May use reports or reporting systems to identify high-risk patient populations.
- Collaborates with cross-departmental teams and/or members of partner agencies to develop care plans.
- Actively participate in multiorganizational care teams and case reviews to provide patients with wrap-around care coordination through diverse community resources.
- Be a clinical resource to non-clinical members of the care team.
- 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.
- Will use a patient-centered approach, including motivational interviewing, on developing care plan.
- Provides care coordination for medically and socially complex patients.
- Meets with patients to assess and identify any unmet health needs.
- Connects patients to community supports.
- Works closely with health care practitioner to develop plan of care.
cht - nurse care coordinator - Morrisville, United States - Lamoille Health Partners
Description
Job Description
Job DescriptionJOB 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.