Job Information
Beebe Physician Network, Inc Care Coordination in Lewes, Delaware
This job was posted by https://joblink.delaware.gov : For more information, please see: https://joblink.delaware.gov/jobs/1235015 Summary:
Working in a remote, home office setting, this individual is responsible for providing phone follow-up and care coordination services for Beebe Medical Group (BMG) attributed and unassigned patients discharged from Beebe Healthcare inpatient, walk-in, or emergency department setting. The focus of the role is on improving the patient experience of care, improving population health and transitions of care, ensuring high quality outcomes and reducing unnecessary, avoidable utilization of the ED and inpatient hospitalizations. Strong customer service and communication skills, and vast knowledge of area community resources and services is required. Assists with Beebe Population Health programming and implementation as directed, working with patients, families, caregivers, and providers as part of an interdisciplinary team to provide care coordination. Ability to assess, plan, implement, coordinate, monitor, and evaluate health care options and services with the goal to optimize patient health status across the care continuum. Capacity to integrate best practices, chronic disease prevention guidelines, protocols and other metrics in development of treatment plans that are patient-centered, promote quality and efficiency in the delivery of care. Responsible for facilitating clinically integrated care and maintaining current knowledge of transition of care best practices.
Responsibilities:
Identifies, tracks, and performs outreach and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services
Reaches out to high-risk patients as identified through risk stratification to ensure any social determinants of health (SDOH) are identified and addressed
Assists patient and families to identify social, medical and financial needs and barriers.
Identify opportunities to close gaps in care for patients
Develop/run monthly reports of preventive and chronic care that is due and complete outreach to patients to schedule/notify
Identification and Solutions for Patient Barriers to Care
Navigates referrals to the CHWs to facilitate the support of patient care needs such as transportation, insurance, housing, food, and other community resources to include attaining or completing applications for such services.
Work with patients and community-based organizations (CBOs) to identify barriers to care with the goal of finding solutions and resources to remove barriers to care.
Leverages local agencies throughout the community to assist patients with getting referrals for the services they need
Address patients social determinants of health (SDoH)
Help patients obtain the care they want and need when they need it
Continuously add to current list of community resources for patients.
Assist patients with navigating the healthcare system.
Care Transitions
Ensure a smooth transition of care for patients seen or treated in an ED, Walk-in, or as an inpatient.
Identify and track patients discharged from the inpatient service
Ensure patients discharged from the hospital are seen within 7-14 days of discharge.
Complete post-discharge calls to patients within 72 hours of discharge according to standard scripting (medication review, upcoming appointments, plan of care as outlined by hospital, etc.)
Ensure needed documentation is in patients\' electronic charts
Schedule appointments and ensure appropriate resources are available to facilitate appointment attendance
Work with Population Health Care Coordination Nurses to prevent unnecessary emergency visits and hospital admissions
Collaborate regularly with Population Health Care Coordination Nurses and APNs to identify rising risk patients and patient situations that require intervention.
Schedule any po sible follow-up, test or referral patient appointments
Develop relationships with PCPs, specialists and CBOs