1. Identifies patients requiring care management and takes the lead as care Coordinator for those requiring intervention, especially with socially complex cases. Interviews patients and families to assess current strategies for self-care and available support systems to manage their health.
2. Collaborates with the health care team to develop a psychosocial plan/support plan of care including but not limited to self-management activities, assuring appropriateness of services, assuring individualized support and education, determining the need for continued services, planning for care transitions and identifying and connecting the patient and families with available community resources as needed. Helps facilitate the safe care of patients, including facilitating the appropriate exchange of information among all caregivers.
3. Participates in co-visits with providers using a multidisciplinary approach as needed.
4. Serves as support to SCL Health for population management, patient self-management, along with support and tracking and intervening with high utilizers and those identified as medically at risk.
5. Partners with community resources and community referrals sources as well as build new relationship with the direct community for patient care needs.
6. Completes required documentation according to departmental standards.
7. Participates in clinic and team Quality Improvement processes and patient safety initiatives. Identifies potential areas for improvement including processes that could be streamlined or revised to improve patient satisfaction and outcomes.
8. Promotes mission, vision, and values of SCL Health, and abides by service behavior standards.
9. Performs other duties as assigned.