Patient Care Coordinator
Georgetown, DE, United States
This job was posted by https://joblink.delaware.gov : For more information, please see: https://joblink.delaware.gov/jobs/1244326
Job Summary:
The LPN Care Coordinator works in collaboration and continues partnership with chronically ill or high-risk patients and their family/caregiver(s), clinic/hospital/ specialty providers and staff, and community resources in a team approach to:
Promote timely access to appropriate care.
Increase utilization of preventive care.
Reduce emergency room utilization and hospital readmission.
Facilitates health and disease patient education.
Increase comprehension through culturally and linguistically appropriate education.
Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
Supports patient self-management of disease and behavior modification intervention.
Facilities patient medication management based upon standing orders and protocols.
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Essential Responsibilities:
Serve as the contact point, advocate, and information resource for patients, care team, family/caregiver(s), and community resources.
Work with patients to plan and monitor care:
_o Assess patients unmet health and social needs.\ o Develop a care plan with the patients, family/caregiver(s) and provide (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).\ o Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.\ o Create ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time._
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
Work setting:
Clinic
In-person
Office
Outpatient