A Brief Overview
Under the supervision of the Nursing Supervisor for Care Management, Primary Care Institute (PCI), and Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), this position provides safe, age-specific nursing care to patients/families using the nursing process, including planning, implementation/delivery, and evaluation of care, as delegated by the RN Care Manager assigned to the clinical site. The LPN Care Manager will assist with chronic disease care plans and transitional care management; will document using established processes, and report findings to RN Care Manager, and patient's Primary Care Provider.
What You Will Do
- Function in accordance with their scope of practice and professional standards of the Ohio Board of Nursing.
- Exercise professional nursing judgment appropriate to the level of care needed, and prioritize patient acuity and workload demands. Will function with greater level of autonomy by consistently demonstrating ability to participate in collaborative clinical decision making.
- Demonstrates knowledge of care delivery interventions that result in safe practice and positive care outcomes.
- Provide chronic care management support. Contributes to plan of care to include planning, implementation and monitoring outcomes of interventions.
- Provides health and diagnosis specific education for patients and families to promote self-care management and behavior modification interventions.
- Escalate concerns to PCP and RN Care Manager as needed based on changes in patient status or condition.
- Communicate with patient/family to support plan of care and physician orders.
- Support and facilitate advanced care planning for patients and their families.
- Provide 1 on 1 office or virtual visits to provide education, implement and support plan of care.
- Provide transition of care support, including medication review and patients/family/caregiver education on diagnosis and self-care management.
- Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits.
- Collaborate with multidisciplinary team in the coordination of individual patient care needs.
Additional Responsibilities
- Participates in multidisciplinary team to analyze sources of data to identify high risk patients and member groups.
- Advocate for patients by assisting in navigation of the health system.
- Participate in quality improvement initiatives.
- Develops self and contributes to the professional practice of nursing.
- Displays leadership that influences optimal clinical and operational outcomes.
- Performs other duties as assigned.
- Complies with all policies and standards.
- For specific duties and responsibilities, refer to documentation provided by the department during orientation.
- Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
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