RN - Population Health, South Clinic Family Practice
Posted on: August 5, 2022
The Population Health Nurse will promote effective partnerships
between patients, families, nurses, physicians, other qualified
healthcare providers and clinical disciplines to coordinates care
for patients with chronic disease and effectively manages care
transitions and facilitate a "shared goal model". He or she will
partner with the provider care team for successful preventative
care visits to reduce the severity of chronic disease and avoidable
acute illness. He or she will provide effective clinical health
coaching to assist patients with self-management of their chronic
disease and life-style changes to mitigate health risk.
- Core Values consistent with patient/facmily centered
- Demonstrates professional and effective written and verbal
- proactively acts as a patient advocate
- Recognizes, identifies and responds to opportunities for
- demonstrates effective learning skills based on established,
evidence based practice guidelines
- mentoring and coaching of other team members
- Cultivates effective partnerships will ail members of the
patient care team
- delegation of appropriate work and skills in order to optimize
and streamline workflows and interoffice resources
- Provide a coordinated, strategic approach to identify new or
manage an established chronically ill patient population.
- Stratify patient population according to risk to effectively
and efficiently manage patients. Determine frequency of need for
provider appointment and CCM encounters. Maximize use of qualified
clinical staff within the care management team to provide
appropriate non-face-to-face patient contact.
- Collaborate with practice leaders to implement effective
internal tracking systems for patients such as patient panels,
annual wellness visit scheduling, transition of care follow-up
calls/timely provider visits, and CCM non-face-to-face monthly
- Ensure all required elements are documented for CCM and related
AWV component billing.
- Ensure office staff has an effective internal tracking process
to capture results, medication acquisition, missed appointments,
and adherence to follow-up appointments.
- Develop a process to track Annual Wellness Visits (AWV)
scheduling and ensure that patient records are reviewed appropriate
to identify care gaps prior to visit with the provider visit. Post
reminders to secure that all co- morbidities are discussed and
documented during AWV.
- Participate in huddles with provider and care team. Identify
scheduling opportunities, determine special needs for patients
arriving that office/clinic day, identify patients who need care
outside of their scheduled visit, patients overdue for AWV and
those with missed appointments needing rescheduling. Ensure sharing
of positive patient stories or compliments involving care team
- Provide clinical health coaching interventions to motivate
patients and families toward successful self-management of chronic
disease. Effectively partner with provider practice team members to
mobilize needed community resources for the patient and
- In collaboration with the physician or qualified healthcare
provider, develop a care plan based on mutual goals with the
patient, family, the provider's emergency plan, medical summary,
and ongoing action plan, as appropriate. Monitor patient adherence
to plan of care and progress toward goals in a timely fashion, and
facilitate changes as needed.
- Facilitate patient access to appropriate medical and specialty
providers as indicated by physician or qualified healthcare
- attend and participate in all Care Coordination related
trainings and meetings as assigned. Participate and monitor PI
Keywords: CARLE, Decatur , RN - Population Health, South Clinic Family Practice, Healthcare , Decatur, Illinois
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