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Cincinnati

    care coordinator advanced illness program - Cincinnati, OH , USA, United States - TriHealth, Inc.

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    Description

    Job Overview:


    Facilitates advanced care management for an identified client population to improve quality of life , prevent re-hospitalization and/or provide social connection.

    May coordinate patient care services for seriously ill patients through collaboration with the patient , family, caregivers and health care providers in achieving optimal quality of life.

    As a collaborating member of the palliative care team provides pre-visit and follow-up direction and support to the patient, family, and health care providers.

    As a member of the social connection team, provides advance care planning, telephone social support and information on community resources.

    Develops relationships with professional colleagues within the community to enhance the palliative care team /social connections team and the services provided.

    High level focus on empathic communication, customer service and continually strive to perform duties of their job in a manner that will result in optimal patient and provider satisfaction.

    Contributes to process improvement activities and program data collection.


    Job Requirements:
    Associate's degree or diploma in Nursing

    RN

    Registered Nurse

    Strong oral and written communication skills

    Customer service skills

    Ability to work with physicians and other professional colleagues

    Ability to collect data, generate reports, and provide analysis

    Comfortable working with computers and with EMR

    3-4 years experience Clinical Nursing

    Two years of care management experience or equivalent experience in the healthcare environment required

    Hospice/Palliative care experience highly preferred

    Home health experience preferred

    2-3 years experience Professional Nursing Community health, palliative or hospice care


    Job Responsibilities:
    Guides the multi-disciplinary palliative teams.

    Works collaboratively with members of the healthcare team to coordinate the comprehensive plan of care for residential palliative care patients and families, and support care transitions across the continuum of care.

    Proactively coordinates patient and family needs between providers and other members of the healthcare team.


    Collaborates with the interdisciplinary care team, primary care provider, and other providers in the care team (specialty consults, home health agencies, DME teams, and hospice team) to achieve continuity of care and coordination of palliative services.

    Communicates with all relevant service lines to ensure collaboration across the care continuum.

    Identifies intrinsic/ extrinsic barriers (education level, language barriers, financial concerns, and family dynamics) relevant to the patient's care, as well as families and other resources.

    Supports goals of care initiated by APRN and facilitates hospice referrals, as needed.

    Gathers data and assesses patient care needs.

    Callaborates with the APRN to support ongoing assessments of physio-biological, cognitive/ emotional, spiritual, and social needs while managing life with advanced illness.

    Identifies problems that could lead to crisis situations and collaborates with APRN to support goals of care. Actively participates in interdisciplinary team discussions and provides input to provide the best service for patients.

    Promotes evidence-based practices with personal growth and outreach to others. Provides teaching to patients and families related to patients' goals of care and treatment plans.

    Is accountable for mandatory education requirements and professional growth through organizational and national educational opportunities, such as certification, and shared new knowledge with the advanced illness teams.

    Utilizes performance improvement techniques to implement changes which result in improved patient care and office operations. Provides leadership for and participates in the continued development of the care coordinator role within the physician practice.


    Other Job-Related Information:
    The TriHealth Nursing Vision, Mission, and Philosophy speaks to professional development, collaboration, and our nursing culture.

    To achieve excellence in nursing care, TriHealth encourages:

    pursuit of improved knowledge through continuing education classes, formal education leading to advanced degrees, and the attainment of specialty certification; nurse membership in local, regional, and national nursing organizations related to the appropriate nurse specialty; involvement in activities that better the health of our community; nursing research activities and use of evidence-based practice, and all nurses to foster, support, and personally model collaborative relationships amongst nurses, physicians, and other caregivers for the betterment of patient care.


    Working Conditions:
    Climbing - Occasionally

    Concentrating - Frequently

    Continous Learning - Frequently


    Hearing:
    Conversation - Consistently


    Hearing:
    Other Sounds - Consistently

    Interpersonal Communication - Consistently

    Kneeling - Rarely

    Lifting 50+ Lbs - Rarely

    Lifting 11-50 Lbs - Rarely

    Pulling - Occasionally

    Pushing - Occasionally

    Reaching - Occasionally

    Reading - Frequently

    Sitting - Frequently

    Standing - Occasionally

    Stooping - Rarely

    Talking - Consistently

    Thinking/Reasoning - Frequently

    Use of Hands - Frequently

    TriHealth SERVE Standards and ALWAYS Behaviors


    At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members.

    To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:


    Serve:
    ALWAYS...


    • Welcome everyone by making eye contact, greeting with a smile, and saying hello
    • Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
    • Refrain from using cell phones for personal reasons in public spaces or patient care areas

    Excel:
    ALWAYS...


    • Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
    • Offer patients and guests priority when waiting (lines, elevators)
    • Work on improving quality, safety, and service

    Respect:
    ALWAYS...


    • Respect cultural and spiritual differences and honor individual preferences.
    • Respect everyone's opinion and contribution, regardless of title/role.
    • Speak positively about my team members and other departments in front of patients and guests.

    Value:
    ALWAYS...


    • Value the time of others by striving to be on time, prepared and actively participating.
    • Pick up trash, ensuring the physical environment is clean and safe.
    • Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

    Engage:
    ALWAYS...


    • Acknowledge wins and frequently thank team members and others for contributions.
    • Show courtesy and compassion with customers, team members and the community


  • TriHealth Cincinnati, United States

    Job DescriptionJob Overview:Facilitates advanced care management for an identified client population to improve quality of life , prevent re-hospitalization and/or provide social connection. May coordinate patient care services for seriously ill patients through collaboration wit ...


  • TriHealth Cincinnati, OH , USA, United States

    Job Description · Job Overview: · Facilitates advanced care management for an identified client population to improve quality of life , prevent re-hospitalization and/or provide social connection. May coordinate patient care services for seriously ill patients through collaborati ...

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