Care Coordinator (Medical Assistant) (27049)

GENERAL PURPOSE:

Under the supervision of the Care Coordination Nursing Supervisor, this position is responsible for providing care coordination to high-risk patients at Ampla Health. Care Coordinators are responsible for getting patients in to see their primary care physician within 3-7 days of hospital discharge, providing health education and supporting patients in establishing and achieving care and treatment goals.

MAIN RESPONSIBILITIES AND DUTIES:

1. Maintains at a minimum a caseload of at least 150 high-risk patients who were admitted or discharged from the ED or hospital.
2. Conducts daily outreach to assigned panel of patients within 1-2 business days of notification to Ampla Health of patient hospital discharge.
3. Actively enrolls all eligible patients into the Transitions of Care Program.
4. Secures patient discharge instructions and uploads to patient chart.
5. Uses the Ideal Transitions of Care Framework for coordinating care for high risk patients.
6. Provides medication adherence support through facilitation, patient education, and service linkages.
7. Performs quality control for post discharge medication reconciliation by PCP.
8. Conducts patient assessments including but not limited to chronic disease and social needs screenings.
9. Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
10. Assists patients in establishing and achieving care and treatment goals through a documented care plan.
11. Coordinates with Ampla primary care and other departments to achieve patient centered care and optimize patient communication and care.
12. Assists with referring patients to the Chronic Care Phamily Program
13. Maintains an accurate record of outreach, communications, patient needs, and services.
14. Works to achieve TOC program metrics as detailed to Table 1, below.
15. Supports Ampla Health’s mission by providing superior customer service and respecting patients.
16. Strengthens clinical and quality team work and rapport through strong work ethic and individual accountability.
17. Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
18. Treats patients with empathy and respect and conduct oneself in a professional manner.
19. Complies with organizational guidelines and health care laws and regulations.
20. Other duties as assigned by supervisor.

TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS

Topic

Goal

Patients will be contacted within 12 hours of discharge

Ensure that 80% of all patients that had an ER or Hospital visit assigned to Ampla Health were contacted at least once via phone, email, or patient portal to schedule their follow-up appt with their PCP 12 hours after discharge (or Ampla Health notification of discharge).

Increase Post Hospital Discharge Follow-up

Ensure that 50% of patents that had an ED visit had a follow-up visit scheduled with their PCP within 3-7 days of the ED visit (or Ampla Health notification of discharge).

Member Engagement: Kept vs. Missed Appts

Ensure that 75% of scheduled Care Coordination appts (ER/follow-up) were kept.

Member Enrollment into Transitions of Care Program

Increase the total number of patients (who had an ER or Hospital visit) enrolled into the Transitions of Care program to 50%

Medication Adherence

All patients asked if they have and are taking discharge medicat