Chronic Care Nurse Coordinator

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Job Summary

Chronic Care Nurse Coordinator (CCNC) is responsible for providing professional nursing care to patients and proactively supports the efforts to ensure that standards for patient satisfaction, patient safety, and quality of care are maintained, as established by Montefiore Medical Group (MMG) Physicians. This role functions as one of the primary liaisons between patients, staff and physicians and supports MMG.
Works with the facility and collaborative teams and to continue improvement of care delivery for those with chronic illnesses. Promotes interdisciplinary collaboration, foster team work and champions chronic care excellence by identifying risks and barriers which predispose illness, or which interferes with obtaining maximum benefits from medical care. The CCNC will provide clinical nursing oversight to care management staff responsible for managing high risk chronic illness and provide care management services to eligible patients, including the provision of effective education, self-management support, and coordination of health care services as a means to achieve optimal quality of care.
The CCNC behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the healthcare team with commitment to the pursuit of excellence in improving the health status of the community.

Essential Functions

• Works in close collaboration with physicians and other health care personnel; to ensure they are evaluating, educating and managing patients according to standards of care.
  * Observes and evaluates staff clinical to provide feedback as necessary
  * Communication with members of the Chronic Care Team to establish roles and accountabilities when delegating.
  * Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as blood drawing (venipuncture & phlebotomy), assessment and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.
  * Ensures nursing practices of the care team as well as own practices are in accordance with nursing standards, local, state and federal guidelines and organizational policy.
• Evaluate each Chronic Care patient on an ongoing basis, both by phone and in person, to evaluate each patient's condition, degree of control and educational needs as well as to ensure progression of the care management plan and promote achievement of established goals
  * To ensure a patient-centered and well coordinated system for identifying, prioritizing, enrolling, educating, and managing patients in the primary care office setting.
  * To ensure optimal patient, provider and office staff satisfaction with the Chronic Care Delivery Model
• Mutually develops care plans with patients, care providers, significant others and community providers
  * Gains cooperation of patient in managing his/her health to affect change in helping a patient adapt new habits, or change behaviors.
  * Provide patient education in accordance with departmental guidelines.
  * Utilize behavior modification and motivational techniques to achieve desired goals.
  * To ensure patients are knowledgeable about disease condition, preventing disease complications, medications, and warning signs and symptoms of disease progression
  * Maintain current knowledge of disease conditions and treatment guidelines through review of medical literature, attendance at inservices and other appropriate educational forums
  * Develop and facilitate patient-centered educational presentations.
  * Contacts patients with test results and provides recommendations on cases per physician determination and/or standards of care. Adds recommendations to individualized care plan(s) and reviews After Visit Summary (AVS) with patient. Facilitates clinical messages and chronic condition management education to patients.
• Reviews (in collaboration with interdisciplinary team) practice patterns, variances, and quality outcomes for targeted patient populations.
  * Identifies areas for improvement, and proposes action steps to be taken
  * Identifies with collaboration with providers patient action plan to ensure the safe and timely management of disease episodes.
  * Reviews patient charts for missing labs, reports, and/or open orders and reviews as part of care team huddles.
  * In coordination with the Manager, Nursing and Practice Administrator, manages and inventories clinical supplies.
  * Identifies patients who may need point-of-care testing as well as patients with special needs (i.e., transportation).
  * Coordinates outpatient work-up and or treatment plans when patient situation requires it (i.e. further clinical testing, x-rays, and facilitates communication between physicians and health care providers).
  * Pends tests and procedure orders for physician approval and co-signature. Prepares prescriptions or medication refills, for review and signature by provider.
• Communicates with high risk patients on an ongoing basis, both by phone and in person, to evaluate each patient's condition, degree of control and educational needs as well as to ensure progression of the care management plan and promote achievement of established goals
  * Provide direct clinical care as needed.
  * Patient encounters for high Risk & chronic conditions e.g., hypertension or diabetes. This can include;
  * Educate patients about diagnosis, treatment, medications, and needed follow-up.
  * Conduct nurse follow-up visits for HTN management, insulin teaching.
  * Verbal orders with Read Back for Anticoagulation.
  * Identify underlying challenges such as socioeconomic, cultural, physical or language barriers.
• Collaborate with Practice Leadership to implement chronic disease performance improvement initiatives.
  * Implement disease management toolkits to drive facility change and transitions of care management, both in-person and virtual.
  * Learn new technology that can support your work and help drive the ongoing evaluation toward patient care.
  * Meet all appropriate preventive care and disease quality measures.
  * Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge.
  * Work collaboratively with team members to provide outreach and engagement.
  * Collaborate with Clinic clinical, nursing and administrative leadership to drive continuous performance improvement for chronic disease management.
• Evaluate patient's health needs surrounding their condition, facilitate participation,provide education and coordinate health care services, formulate supportive relationships with patients.
  * To provide clinical support, guidance and oversight to staff
  * To educate staff re: new disease management clinical guidelines and programs.
  * To coordinate patients' health care services and treatment plans across the continuum
  * Consult re: appropriate medication regimen
  * Ensure that quality documentation and timely communication
  * Triages urgent same day or double booked appointment requests.
  * Documents progress notes in electronic health.
  * Manages in-basket requests and responds to all requests in a timely manner.

Qualifications

• BSN Required
• MS Preferred
• 1-3 years 2 Years experience as a Registered Professional Nurse Required
• Excellent communication skills, both orally and in writing.
• Experience with adult and pediatric population required.
• Exceptional social emotional intelligence and interpersonal skills.
• Computer literate, particularly with medical databases and reporting, EPIC.
• Knowledge of professional nursing theory, regulations and practices to give and evaluate patient care required.
• Ability to maintain quality control standards required.
• Knowledge of policies and procedures related to infection control, environmental safety and patient confidentiality required.
• Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care required.
• Skill in identifying problems and recommending solutions required.
• Ability to work independently within scope of practice, make appropriate clinical decisions and delegate appropriately required
• OHS Annual Assessment Required
• Registered Nurse New York Required
• Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED) Required
• Basic Life Support (BLS) certification Required