About Job

GENERAL PURPOSE:

Under the supervision of the Care Coordination Nursing Supervisor, this position is responsible for providing care coordination to high-risk patients at Ampla Health. Care Coordinators are responsible for getting patients in to see their primary care physician within 3-7 days of hospital discharge, providing health education and supporting patients in establishing and achieving care and treatment goals.

MAIN RESPONSIBILITIES AND DUTIES:

Maintains at a minimum a caseload of at least 150 high-risk patients who were admitted or discharged from the ED or hospital.
Conducts daily outreach to assigned panel of patients within 1-2 business days of notification to Ampla Health of patient hospital discharge.
Actively enrolls all eligible patients into the Transitions of Care Program.
Secures patient discharge instructions and uploads to patient chart.
Uses the Ideal Transitions of Care Framework for coordinating care for high risk patients.
Provides medication adherence support through facilitation, patient education, and service linkages.
Performs quality control for post discharge medication reconciliation by PCP.
Conducts patient assessments including but not limited to chronic disease and social needs screenings.
Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
Assists patients in establishing and achieving care and treatment goals through a documented care plan.
Coordinates with Ampla primary care and other departments to achieve patient centered care and optimize patient communication and care.
Assists with referring patients to the Chronic Care Phamily Program
Maintains an accurate record of outreach, communications, patient needs, and services.
Works to achieve TOC program metrics as detailed to Table 1, below.
Supports Ampla Health’s mission by providing superior customer service and respecting patients.
Strengthens clinical and quality team work and rapport through strong work ethic and individual accountability.
Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
Treats patients with empathy and respect and conduct oneself in a professional manner.
Complies with organizational guidelines and health care laws and regulations.
Other duties as assigned by supervisor.

TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS

Topic

Goal

Patients will be contacted within 12 hours of discharge

Ensure that 80% of all patients that had an ER or Hospital visit assigned to Ampla Health were contacted at least once via phone, email, or patient portal to schedule their follow-up appt with their PCP 12 hours after discharge (or Ampla Health notification of discharge).

Increase Post Hospital Discharge Follow-up

Ensure that 50% of patents that had an ED visit had a follow-up visit scheduled with their PCP within 3-7 days of the ED visit (or Ampla Health notification of discharge).

Member Engagement: Kept vs. Missed Appts

Ensure that 75% of scheduled Care Coordination appts (ER/follow-up) were kept.

Member Enrollment into Transitions of Care Program

Increase the total number of patients (who had an ER or Hospital visit) enrolled into the Transitions of Care program to 50%

Medication Adherence

All patients asked if they have and are taking discharge medications as prescribed.

QUALITIES & CHARACTERISTICS

Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Health’s staff, Board of Directors and vendors
Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions
Strives to learn more and is receptive to learning different ways of doing things
Displays enthusiasm toward the work and the mission of Ampla Health
Ability to work in a fast-paced, patient service-oriented environment

PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:

High School Diploma
Completion of Medical Assistant
Strong problem solver
Possesses outstanding interpersonal skills, including excellent written and verbal skills
Ability to connect and engage patients in person and over the phone
Demonstrates ability to promote quality improvement through development and maintenance of standards
Sensitive to the needs of the cultures represented in the Ampla Health patient population
Demonstrates clear knowledge of Ampla Health’s clinic structure, standards, procedures, and protocols

COMMUNICATIONS SKILLS:

Must have neat and legible handwriting
Must be able to interact with patients courteously and calmly
Ability to communicate well with the public

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:

Must be in good health and able to lift up to 40 lbs
Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff
Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning