Population Health Nurse

Job Details:

Job Location:

Gordon Rushville Clinics - Gordon, NE 69343, POSITION SUMMARY

The Population Health Nurse responsible for bringing together the patient, healthcare providers, and community resources in the planning, implementation, and evaluation of comprehensive healthcare. Primary responsibilities will include identification of Medicare patients appropriate for Annual Wellness Visits and execute guided processes to complete the visit. They will effectively coordinate and manage high-risk chronically ill patients through Chronic Care Management utilizing health coaching techniques to assist patients with self-management of their chronic diseases and lifestyle changes to mitigate health risk.

This position may also be responsible for other programs to include Transitional Care Management, coordinating efforts with Post-Acute Care clinicians (Skilled Nursing Facilities and Home Health), or integration of Behavioral Health services

• Attend and actively participate in GMH population health related trainings and meetings.
• Work collaboratively with ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to the patient’s visit with Primary Care Provider;
  Post reminders to ensure all co-morbidities are discussed and documented during AWV.
• Establish competencies related to AWV screenings such as PHQ-9, TUG, and Mini-Cog and assist in training of the Primary Care Team to perform these screenings.
• Establish counseling services/resources to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety, and advanced care planning.
• Collaborate with community partners to develop and implement programs that address social determinants of health.
• Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for clinician visit and CCM encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
• In collaboration with Primary Care Team, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan, progress toward goals, and facilitate changes as needed.
• Participate in huddles with Primary Care Physician and Care Team; identify scheduling opportunities, special needs for patients with appointments that day, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling; ensure sharing of positive patient stories or compliments involving Care Team efforts.
• Collaborate with Primary Care Team to implement effective internal tracking systems for patients such as patient panels, AWV scheduling, transition of care follow-up calls/visits, and CCM encounters
• Collaborate with ACO team to establish a method for assigning patients into a panel listing by Primary Care Provider that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers
• Serve as a resource to other healthcare professionals on population health topics.
• Advocate for and Develop policies and procedures that improve population health.
• Provides oversight of Medication Aide training and annual clinic staff competencies.
• Serve as back-up Outpatient RN and Specialty Clinic Coordinator.
• May assist with vaccine clinics for all patient populations.
• Serves as back‑up VFC coordinator.
• All other duties as assigned.

The Population Health Nurse helps…