Position Summary & Essential Duties:
This position is responsible for providing direction for designing, implementing, and supporting the APP practice model within the care management/ care coordination services of UH Population Health (a population health service organization (PHSO) for UH Quality Care Network; a clinically integrated network (CIN) and UH Accountable Care initiatives (Medicare Shared Savings Program, Commercial and Medicaid).
This position will collaborate with and engage leadership, administration, professional, clinical and other staff throughout the organization to implement population health programs and promote a culture consistent with the health system’s mission, core values, and standards of conduct.
Key responsibilities include:
• Performs patient assessment and assigns diagnosis based on recorded assessment data and current scientific and current research
• Establishes plan of care and implements interventions in accordance with care paths, protocols, and standards of care and current research
• Monitor the effectiveness of therapeutic interventions
• Reduces risk factors and barriers to care, addressing complex, co-morbid conditions, and social determinants of health
• Collaborates with other health care providers in an interdisciplinary approach to provide care to the patient and family
• Order and perform routine diagnostic procedures
• Contributes to the educational development of staff, patients, family and self
• Provides education through role modeling and in-services to meet identified learning needs and to promote professionalism
• Conducting regular telephonic outreach to UHACO members with a focus on coordinating individual patient care by partnering with members of the health care team to develop individual, trusted relationships with patients to guide them through:
• Routine preventive care, health maintenance visits, and diagnostic services
• Hospitalization and post-discharge services including the use of Home Care, SNF, Rehabilitation, Palliative and Hospice levels of care
• Reducing risk factors and barriers to care, addressing complex, co-morbid conditions, and social determinants of health
• Developing longitudinal care planning that includes assessment, planning, implementation and monitoring
• Coordinating continuity of care with patients and families following hospital admission, discharge and ER visits
• Engaging at risk members to develop specific care plans to address health concerns, gaps in care and individual challenges in order to achieve an optimal level of wellness and functional capability
• Demonstrating a thorough understanding of, and ability to connect patients with, available resources in the Northeast Ohio community focused on improving the health, wellness, and overall quality of life for a patient.
• Analyzing various sources of data to identify at risk patients and member groups, then developing specific care plans to address health concerns, gaps in care, and other challenges.
• Partnering with UHACO team members to support patients, their families, and physicians in addressing barriers to medical care.
• Connecting UHACO members with various UH Population Health team resources to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the cost of health care