Memory Care Navigator

Williamsburg, Virginia

The Memory Care Navigator is responsible for outpatient complex care coordination for persons living with memory loss and their family caregiver(s). This care coordination will include supportive care through a triage process, caregiver education, resource referral, and ongoing support for those living with dementia and their family caregiver. The Memory Care Navigator will prioritize outreach efforts to underserved and marginalized populations.

The Memory Care Navigator strives to promote coordinated care in order to improve outcomes, efficiency in utilization of health care services and increased quality of life for families who are caring for loved ones with memory loss.

• Proactively identifies and evaluates patients and their families for care management from a variety of sources to include PAA, Old Town Medical, Lacky Free Clinic, Riverside Charlie W. and Golden Bethune Hill Community Health Clinic, Riverside Family Medine at the Brentwood Medical Center, RHS internal reports, discharge/disposition planning, referrals in the health system, referrals outside RHS, team members, and team members at the Geriatric and Memory Care Clinics.
  
  Collects and documents clinical and psychological patient needs in the patient’s home, when applicable, or within RHS in the acute care hospitals, ED, or clinical provider office. Conducts systematic ongoing thorough collection of patients physical, emotional, psychological, social , and medical status from patient, caregiver/family, PCP, or other relevant sources such as electronic health record. Evaluates the quality and necessity of health care services and makes recommendations for an alternative level of care or care coordination such as:
  Home Health, Palliative Care, Hospice, GUIDE, GAC, Driving assessment, Respite, Medication Review, Adult Day. Memory Café or Support Groups. Invites patient and caregiver/family to actively participate in plan of care.
• Develops an appropriate patient-centered and patient specific Care Plan to include short- and long-term goals, objectives and actions and partners with the patient and family in the development of the plan of care. Coordinates, collaborates, and obtains approval of the plan with the patient, family/caregiver, primary provider and other members of the healthcare team. Guides the patient and family/care giver through the healthcare system, maximizing use of resources.
  
  Coordinates and executes the plan of care, optimizing access to appropriate services. Ensures necessary referrals are ordered by the appropriate discipline and coordinated.
• Serves as an advocate for, and ensures education is provided to, the patient and family/caregiver as required. Collaborates with the patient’s PCP and specialists in the development of the plan of care to ensure the patient’s needs are addressed; communicates care objectives to appropriate individuals/departments/referral sources. Promotes adherence to the Care Plan for improved healthcare outcomes. Collaboration with caregiver/family goals related to patient centered care.
• Documents and updates the Care Plan in designated EHR. Maintains documentation and data collection in accordance with RHS policies and procedures. Conducts and/or participates in program evaluation as directed. Monitors and evaluates patient's adherence and response to the treatment plan, timeliness of patient and family/caregiver contact and follow-up, identification of variances, patterns and trends from established practice guidelines and/or standards, established outcome measurements, treatment delivery and timeliness.
• Provides assistance, support, and referral services to community partners for the person living with memory loss and the family/caregiver to ensure identified education, and appropriate timely care is received.
• Anticipates the patient’s needs and encourages patients and families to actively participate in the plan of care. Establishes working relationships with referral sources and community resources.
• Provides assistance, support, and referral services to community partners for the person living with memory loss and the family/caregiver to…