Collaborates with practice staff in identifying appropriate patients for chronic care
management.
? Formulates and implements a chronic care management plan that addresses the patient's
identified needs by assessing the patient/family needs, issues, resources and care goals;
determining the choices available to individual patients; educating the patient/family on the
choices available.
? Establishes a chronic care management plan that is mutually agreed upon by the health care
team and the patient/family. Plans will contain specific mutual self-management goals,
objectives, and interventions with the patients are action-oriented.
? Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as
needed to reflect changing needs, issues and goals. Collaborates with the healthcare team when
changes occur. Monitors and evaluates the progress of the patient. Initiates care conferences to
discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
? Identifies and effectively utilizes community resources to meet the needs of patients/families.
? Promotes patient self-management and empowers patients/families to achieve maximum levels
of wellness and independence.
? Interacts professionally with patient/family and involves patient/family in the formation of plan
of care.
? Maintains regular, ongoing contact with clients, caregivers, specialists and service providers
through home visits and phone calls.
? Manages care transitions, which may include home visits, including providing referrals and
facilitating follow-ups for the patient upon discharge from medical facility. Performs
medication reconciliation for all care transitions.
? Provides coverage across HBPC as needed. This may include clinicaltasks .
? Participates in community health activities.
? Participates in regular team meetings, peer review activities, and quality and organizational
committees.
? Participates in the orientation of new personnel. Precepts and mentors peers. Promotes
collaborative teamwork.
? Abides by the organization's compliance program and requirements.
? Works collaboratively with leadership team to improve and enhance care delivery through the
evaluation, development and enhancement of policy and procedures.

Oversees high risk chronic illness patients to promote effective education, self-management support and
timely healthcare delivery to achieve optimal quality and financial outcomes. Establishes and manages
patient chronic care plans, which includes developing realistic goals and objectives, to address clinical,
social,and behavioral needs. Collaborates with healthcare staff to develop, implement, monitor, and
evaluate appropriate clinical care or services. Manages care transitions, which may include home visits,
including providing referrals and facilitating follow-ups for the patient upon discharge from medical
facility. Oversees Remote Patient Monitoring and responds accordingly. Supports Home-Based Primary
Care Nurse Practitioner clinically as needed.