LPN Care Coordinator

Description

POSITION SUMMARY

Matrix Organizational structure with direct line to Physician Lead of each team for population management outcomes and an indirect line to Practice Manager for completion of TOC and high-risk patient management per policy and related nursing documentation.

REPORTING RELATIONSHIPS

This position reports to the Nurse Manager. The position works directly with clinical staff, residents, physicians, providers and practice managers.

LPN CARE COORDINATOR

While living and demonstrating our Core Values, the LPN Care Coordinator will:

• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that have experienced any transition from a healthcare facility (i.e. ED, hospital, rehabilitation facility, SNF, etc.) to home including follow-up phone calls and the coordination of follow-up visits with the primary care Provider-Team to include:
  • Obtaining daily list of patients admitted and discharged from the hospital, using My Patient Your Patient Software, and meeting with GHP Case Manager to determine accountability for patient TOC management. If the GHP Case Manager is absent, the LPN CC is responsible for completion of all TOC calls and related patient management and for communicating daily with the GHP Case Manager replacement to review TOC data for GHP and Medicare fee for service patients
  • Call assigned transitional care patients within 48 hours of discharge to collect and document information and data from the patients about symptoms, functional status, safety, and support at home, current complaint/s, and medication reconciliation
  • Arrange follow-up visits for transitional care patients with the Primary Care Provider-Team within 2-7 days post discharge based on patient needs (within 2-3 days if symptoms not managed, functional status concerns, safety issues, no support at home, medication non-reconciliation)
• Responsible for the care coordination of assigned panel patients (including but not limited to non-Geisinger and non-Medicare fee for service patients) that are medium risk, rising risk or high risk and Rising Risk Registry of Patients to include:
  • Run the high-risk stratification tool on a monthly basis, reviewing the list with the lead panel Provider to identify/verify the list high risk panel patients, and then adding high risk patients to Care Coordinators’ high-risk registry (list excludes patients managed by GHP Case Manager)
  • Coordinate care of at least 30 high risk patients and rising risk patients within the assigned panel (excludes patients managed by the GHP Care Manager)
  • Obtain and document information and data from the patients about vital signs, symptoms, functional status, safety and support at home, socioeconomic status, current complaint/s, and medication reconciliation
  • Review and document the education plan with patients to include use TWC-specific handouts that address basic disease information, symptom management, functional status concerns, safety issues, and medication information and administration information
  • Assist patients with self-management goal setting to improve healthy behaviors and manage chronic illnesses or conditions
• Bill the CC charges on a daily basis per procedure
• Facilitate the weekly Huddle at MVP
• Attend monthly ACO meetings
• Manage at least 30 TOC cases at all times

MEDICATION MANAGEMENT

• Complete IV rehydration to patients as assigned
• Monitor Home INR and Coumadin Safety Program as assigned
• Ensure immunizations and medications are in stock
• Prepare and administer medications and injections as per physician or physician extender in absence of registered nurse

PATIENT CARE

• Coordinate timely referrals of patients with socioeconomic issues that interfere with treatment access, transportation, or patient safety to the social worker.
• Conduct lab draws, laboratory testing, and Point of Care testing and will observe, guide and direct Resident blood draws
• Initiate and monitor insulin pumps per physician orders.
• Conduct ambulatory Blood Pressure Monitoring applications
• Conduct reading PPDs
• Triage all panel patient calls and provide consultation in considerate and respectful manner
• Monitor the closure of labs, diagnostic tests, referrals, and orders for panel patients
• Track and address partial labs and engage Residents to assist in
• Ensure labs are addressed timely
• Observe, guide and direct Resident blood draws
• Ensure quarterly resident evaluations by patients, staff and physician preceptors to