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    care coordinator advanced illness program - Cincinnati, United States - TriHealth

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    Description

    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 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 NursingRN Registered NurseStrong 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 EMR3-4 years experience Clinical Nursing Two years of care management experience or equivalent experience in the healthcare environment requiredHospice/Palliative care experience highly preferredHome 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 - OccasionallyConcentrating - FrequentlyContinous Learning - FrequentlyHearing: Conversation - ConsistentlyHearing: Other Sounds - ConsistentlyInterpersonal Communication - ConsistentlyKneeling - RarelyLifting 50+ Lbs - RarelyLifting 11-50 Lbs - RarelyPulling - OccasionallyPushing - OccasionallyReaching - OccasionallyReading - FrequentlySitting - FrequentlyStanding - OccasionallyStooping - RarelyTalking - ConsistentlyThinking/Reasoning - FrequentlyUse of Hands - FrequentlyTriHealth SERVE Standards and ALWAYS BehaviorsAt 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 areasExcel: 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 communityAbout UsCareers at TriHealth are diverse. From clinical to administrative, sales to service, our team members contribute skills that are as varied as the services we offer and the people we serve. As an employer, TriHealth demonstrates the organization's values by offering comprehensive benefits packages, competitive wages, and milestone recognition. Explore our career options to help you determine the type of job best for you as well as help narrow your search within our website. We look forward to you joining the TriHealth familyAbout the TeamNurses are at the heart of patient care, and we are proud to have such amazing nurses here at TriHealth. As the region's leading health system, we are focused on consistency in the patient experience and standardizing nursing care across the system with proven best practices. We aim to continue leading research supporting the evolution of nursing care, especially as TriHealth works to adapt the population health model system-wide. In order to lead these changes, TriHealth must invest in our nurses, which is why we provide multiple opportunities for nurses to achieve their professional development goals through tuition reimbursement programs, specialty certifications and several other continuing education opportunities. Our registered nurses support TriHealth in many different aspects of nursing, including patient care, care coordination, education and management. If you're interested in joining our world-class nursing team, you can see all current nursing opportunities here on I am honored to lead our TriHealth nursing team, and welcome you to join us


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