PURPOSE OF THIS POSITION
The Care Navigator provides intensive physician-office-based case management support for a case load of patients in the Patient Centered Medical Home program sponsored by BVHS and Hancock Medical Group, the Comprehensive Primary Care Plus program and other managed care programs as developed. The Care Navigator's role is to aid patients who have complex health needs in improving their health or managing their chronic condition, through individual counseling sessions, telephonic or electronic contacts, office visits with physicians, and some home visits. By providing case management for patients and involving the patient's family, the Care Navigator focuses on patient education and compliance with the care plan, including medication adherence. The Care Navigator works closely with Medical Home/primary care physicians for development of the care plan and case management, and is embedded in the physician offices. The Care Navigator works closely with hospitals, home care and other providers to coordinate transitions across the care continuum and arrange access to community resources needed by patients. The Care Navigator uses computer systems and tools for population management activities, to identify potential patients for case management, for access to patient information and for documentation of Care Navigation activities. The Care Navigator plays a key role in developing and implementing the programs.
Duty 1: Establishes regular communication and works on site in physician offices to accept referrals of patients to the Care Navigator program and to case manage the patient load. Serves as a clinical resource/consultant to physician practices to optimize communication and effective utilization of health care resources.
Duty 2: Identifies and prioritizes patient caseload using the CPC+ high risk patient identification process, daily admission and ER visit reports, the Medical Home registry, medication compliance profiles, physician and office staff referral, patient self-referral, and other means approved by the Medical Management Committee and CPC+ program administration.
Duty 3: Manages the following caseloads of patients: 1) patients with chronic or high risk conditions in order to assess patient needs, coordinate care and attain quality and cost effective outcomes; 2) patients making a transition of care from inpatient to another setting or from skilled nursing to another setting, in order to coordinate care and services, prevent unnecessary readmissions or emergency visits post discharge, and support patient adherence; 3) patients with frequent emergency department visits in order to coordinate care, assess and address unmet care or access needs, improve adherence, educate and avoid unnecessary future emergency department visits. Care navigator may have a caseload of pediatric patients to provide care coordination and chronic condition management support.
Duty 4: Utilizes nursing processes to assess and plan strategies for patient care with emphasis upon appropriate resource utilization, appropriate levels of care, quality and patient and family education. Develops and implements plans of care which address the specific diagnosis, age, gender, psycho-social and emotional needs of each patient, and which are culturally sensitive.
Duty 5: Establishes and maintains communication/collaboration with the interdisciplinary team across the continuum of care (inpatient case management, home care, SNF care) and with the patient's primary physician regarding patient condition, orders, plan of care, anticipated needs, and progress.
Duty 6: Evaluates patient access to needed services and coordinates access to the care continuum and community resources. Maintains active communication and collaboration with BVHS entities and community agencies and resources to assist patients and families to gain access to these services. Appropriately refers patients with physician approval to appropriate resources for education, services, and resolution of care issues of the patient.
Duty 7: Counsels directly and often in person with patients and families to promote education, care plan compliance and improved health of patient. Communicates with patients in person, via telephone, text, letter and email. Attends physician office visits to primary care physicians or specialists when appropriate for the patient's care plan. Conducts home visits to patients as appropriate.
Duty 8: Manages, documents and reports on caseload including documenting plans and contact records, tracking and evaluating case management activities and outcomes on an individual and aggregate basis. Outcomes include quality, compliance with care guidelines, costs, resources used, and patient and physician satisfaction. Uses electronic documentation system for patient documentation and care management, concurrently (not delayed or "bulk" documentation).
Duty 9: Serves as clinical resource to EDOC Medical Management Committee and CPC+ program administration in the development of evidenced based guidelines and in the development and evaluation of data and reports. Participates in various committees and prepares reports to contribute information regarding utilization of services and quality of healthcare for the purpose of improving patient care and outcomes.
Duty 10: Works with data analyst to collect, manage and analyze data specific to patient and provider population. Helps analyze aggregate data for trends and outcomes and to measure performance of program and providers on goals and objectives. Utilizes data findings and provider and patient feedback to evaluate program strengths and weaknesses and to identify and implement areas for improvement.
Duty 11: Provides coverage for other care navigators as required. Manages on-call assignments as required effectively including timely physician and patient communication, record keeping, and keeping management informed of any unusual or special incident occurrences.
Duty 12: Displays Service Excellence as evidenced by practicing the mission, vision, and values of the organization to promote patient satisfaction.