Title: RN Health Coach - Mercy Perry Clinic - FT (days)
Location: IA-Perry-Mercy Perry Clinic
Works collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients within the physician office setting. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained. Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population. Works closely with the MCI Quality Committee Team and the Director of Quality.
Provide oversight of the disease registry database including:
a) Assuring database is kept up to date.
b) Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.
c) Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
d) Creating patient, physician, and clinic level quality performance reports.
Provide oversight or conducts pre-visit chart review of patients including:
a) Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.
b) When standing orders allow it the interventions may be ordered or completed before the patient sees a provider.
c) Fills out pre-visit forms or initiates office visits forms to communicate the review to the provider.
Works with patients and families on Self-Management Support including:
a) Setting short and long-term goals for self-management of chronic disease.
b) Addressing medication adherence in patients not meeting outcome goals.
c) Works with patient to create a plan for Health Behavior Change utilizing the 5A's approach
§ Assessing and working on the patients readiness to change, the importance of change, and confidence in ability to change.
§ Helping the patient to identify and overcome barriers
d) Makes a plan for follow-up between visits
e) Provides needed patient education regarding specific health care skills and general disease concepts.
f) Assist with shared medical appointments.
g) Communicating face-to-face in the office setting, by telephone, or by e-mail.
Provides Coordination of Care across the care continuum including:
a) Assists as liaison with patients and their families to physicians, clinical staff, and other departments.
b) Acting as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital discharge.
c) Acting as a liaison with specialty clinics.
d) Proactively acts as patient advocate, responding to and working to resolve patient concerns
e) Providing a link to community resources
Involvement in QI activities :
a) Assesses clinic needs and then collaborates with Clinic Manager on strategies to achieve individual clinic level goals such as quality and efficiency.
b) Actively participates/coordinates committees as needed/requested, i.e. Performance Improvement Teams.
c) Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.
d) Meets on a regular basis with other MCI population health managers, as coordinated by Clinic Administration, for information sharing and continuing education activities.
MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:
· Licensed by State of Iowa as an RN, BSN preferred.
* Clinic/Physician office experience preferred.
* Experience in patient education preferred.
* Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills.
* Certification as Healthcare Coach within one year
* CPR Certification
* Mandatory Reporting Certificate (obtain within 45 days of start date).
* Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
* Adheres to and exhibits our core values:
Reverence:Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
Integrity:Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
Compassion:Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
Excellence:Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
* Maintains confidentiality and protects sensitive data at all times.
* Adheres to organizational and department specific safety standards and guidelines.
* Works collaboratively and supports efforts of team members.
* Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.
Catholic Health Initiatives and its organizations are Equal Opportunity Employers
Job: Quality Management
Status: Full Time