Overview
This is a full-time position for an LPN, providing care coordination/management along with implementing prescribed medical treatments, to include patient care and education services. The LPN will work with ill, injured, convalescent, and disabled patients. The LPN role will include the provision of care coordination including Medicare Wellness Visits, Chronic Disease Care Management, and Transitional Care Management for high-risk patients. The team care member will assist with implementing quality improvement measures to aid in preventing and managing chronic diseases.
Responsibilities
- Coordinates and provides Medicare Wellness Visits to eligible patients in the primary care practice, completing documentation.
- Utilize Excel spreadsheets to track patients due for Medicare Wellness Visits.
- Call and schedule patients due for visits.
- Track visits completed using Excel.
- Work with Medical Assistant and other practice team members. Review patient lists, quality measures, outreach lists and coordinate care for those members who are in need of Medicare Wellness Visits or identified as having quality gaps.
- Attend Care Management Meetings, Primary Care Collaborative meetings, and other educational sessions as scheduled. Complete recommended educational modules as assigned.
- Follow chronic disease and preventive care guidelines and ensure that appropriate plans for completion are developed.
- Assist patients in developing a personalized wellness plan that includes realistic goals and a plan of action, including advanced care planning.
- Provide education and support to patients in learning how to make good choices for themselves that will lead to optimal well-being and a higher quality of life.
- Promote patient engagement and compliance with appointments, treatment recommendations, and other recommended services.
- Complete all tracking and reporting requirements for outcomes and evaluation.
- Assist physicians with examinations, minor surgeries, diagnostic procedures, and treatments.
- Assist in clinic with rooming and triaging patients. Provide basic patient care as ordered.
- Phone triage, patient scheduling, calling pharmacies. Authorize refills. Respond to tasks and patient messages.
- Assist with specialty clinics including Coumadin Clinic, Colposcopy Clinic, Minor Surgery Clinic, Flexible Sigmoidoscopy, and Treadmill Clinic.
- Process Mirena, Paragard, Implanon/Explanon requests. Talk to patients, answer questions, and schedule appointments.
- Administer injections of medications or immunizations in accordance with approved nursing protocols. Observe patients for any reactions to medications or immunizations.
- Respond to life-threatening situations based upon nursing standards, policies, procedures, and protocols.
- Prepare exam rooms for patients, restock supplies, sterilize instruments, and maintain medical equipment.
- Maintain knowledge of all office procedures: ECG, in-house labs, spirometry, administration of nebulizer treatments, insertion and monitoring of IVs, Holter Monitor, assistance with minor surgical procedures and GYN procedures.
- Document all nursing interventions in the electronic medical record. Review the chart for completeness, test results, and billing.
- Scan upcoming appointments for additional medical record information. Obtain medical records from other physician offices, hospitals, labs, emergency rooms, and radiology departments prior to patient visits.
- Complete all tasks assigned to the individual team, including responding to patient messages, prescription refills, lab results, referrals, and home health agencies.
- Respond to questions from patients, family members, faculty/residents, and other health care providers in a timely and professional manner.
- Follow EVMS protocols related to infection control, environmental safety, and patient confidentiality. Complete annual recertification for OSHA, Blood Borne Pathogens, Compliance, Respiratory FIT, and IT policy. Maintain current CPR certification and nursing license.
- Nursing staff is required to fill in for other clinical staff during vacations and illness.
LPN Role Post Visit
- Provide care plan from visit to include:
- Medication list
- Individualized patient goals
- Review of chronic diseases
- Health screenings due
- Schedule Preventive/screening tests including referrals for TMT, vasectomy, minor surgery, GYN clinic.
- Diabetes Education including reviewing diabetic flow sheets and teaching self-glucose monitoring and insulin administration.
- Coordination of transitions of care from the hospital to LTC.
- Communication with continuity providers.
Team Care member participates in SENIORS CLINIC
- Family counseling to include:
- Care preferences
- Advance directives
- Caregiver stress support
- Bereavement support
- Perform functional mood and cognitive assessments.
- Coordinate transitions of care.
- Perform other duties as assigned.
Qualifications
Must be a licensed LPN in Virginia. One year of LPN experience preferred. Completion of BLS class and re-certification every two years. Ability to make professional nursing decisions up to the scope of practice for licensure and possess the knowledge and critical thinking skills to support those decisions. Possess complex patient assessment and management skills to develop a care plan for Medicare Wellness Visits. Possess basic knowledge of educational behavioral approaches to change behavior. Maintain professional interaction skills with physicians, patients, outside offices, pharmacies, referring agencies, hospital personnel, and support staff.
Location: US-VA-Portsmouth
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