Care Advocate Nurse

Major Responsibilities:
The LPN Care Coordinator works under the direction and supervision of a Licensed RN/SW within the department. He/she coordinates care in collaboration with patients’ primary care physician team/office, hospital care managers, Care Transitions Team, post acute care managers, and RN/SW care partners aimed at providing a model of patient care that ensures the delivery of quality, efficient, and cost-effective healthcare services.

He/she may work embedded within an APP/AMG PCP or OB/specialist practice, or telephonically working with a care team.

1)
Receives referrals from licensed clinician for patients that have chronic, co-morbid conditions that are not within clinical goals, may have psychosocial issues contributing to non-adherence to their PCP/SCP's treatment plan. Contacts the patient and completes the questions in the department initial assessment within the department's EMR following department guidelines on content and timing. Completes the case criteria that recommends the case type- complex care management, disease management or care coordination based upon the results of the initial assessment.

2)
Communicates pertinent clinical and nonclinical patient information to physician by phone, email, practice EMR to affect appropriate outcomes.

3)
Develops and implements a Plan of Care for each patient from the outcome of the initial assessment, knowledge of the PCP and SCP's treatment plan including the patient's goals of care. The care plan focuses on the patient's active conditions and goals/interventions are prioritized using the clinical vulnerability that could result in potentially avoidable utilization. The care plan must also include barriers to reach the goal, time frames and action steps to meet each goal.

The LPN Care Plan is reviewed and approved for accuracy and completeness by a licensed RN/SW within the department.

4)
Utilizes evidence-based guidelines and protocols to educate/coach patient regarding resources, healthcare navigation, care needs and disease process.

5)
Collaborates with inpatient/SNF/HH care managers on difficult or complicated cases to facilitate a timely discharge and smooth care transitions between inpatient, SNF and homecare . Complies with department standards and guidelines of handing in information to the Inpatient Care managers within 24 hours of admission as well as member contact within 48-72 hours after members are transitioning from hospital or SNF home to promote safe transitions of care.

6)
Monitors member progress against the established plan of care to promote early intervention in acute situations. Patient contact frequency is determined by the care plan action steps and can range from daily, but no less than monthly. Reviews the plan of care monthly and adjusts the plans needed by identifying and overcoming barriers to care. Any changes to the patient care plan is re-reviewed by a licensed RN/SW from within the department.

7)
Demonstrates effective patient-engagement techniques, to maximize patients engaging and maintaining their active participation in care management . Demonstrates focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, employers, patients, and families with diverse opinions, values, and religious and cultural ideals.

8)
Collaborates with contracted/noncontracted vendors, community agencies/resources to provide timely services including quality outcomes, patient and physician satisfaction, cost and service levels. Coordinates and implements referrals by communicating directly with physician, patients/families, vendors, employers, agencies, HMOs, Medical Director, UM staff, Hospital Staff and other appropriate ancillary providers on a regular basis.

9)
Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of patient care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the population served by Advocate Care.

As delegated by his/her licensed supervisor or assigned PCP, the LPN CC ,manages timely completion of activities…