A Patient Navigator works closely with primary care physicians and various specialty physicians and services to maximize the health status of patients. This position requires a high frequency of contact with the very high risk ACO patient and their care givers for education of health promotion and self care skills as well as facilitating compliance with the required quality measures for all ACO patients. A Patient Navigator will also ensure the coordination and communication of a patient’s treatment plan and general status to all care givers during all transitions of care. This position requires advanced nursing knowledge and expertise to identify and implement improvement processes and the ability to direct and implement care coordination plans both in both in-patient and out-patient settings.
Essential Generic Job Functions(List in order of importance):
- Perform a needs assessment of very high risk patients (with their input) to maximize or improve current health status and independence while preventing or slowing deterioration of existing health problems.
- Ability to perform extensive telephone assessment and triage of patients.
- Able to review office charts to identify gaps in care and coordinate services and the care team to manage these issues.
- Work within a multi-disciplinary team to develop and implement a comprehensive plan of care for very high risk Medicare ACO patients.
- Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care. Work within the multi-disciplinary team to create new and update existing tools.
- Identify patient and care giver learning needs, assess their ability to learn, then formulate a comprehensive teaching program individual to that patients unique health issues.
- Work collaboratively with physicians to ensure patient adherence to medical plan, including all appropriate preventative and disease-specific screenings, interventions, and treatment goals including self-management goals.
- When necessary or as directed, travel to patient locations such as hospital, skilled nursing facility, etc. to assess patient needs and status.
- Assist patients and their care givers in obtaining referrals to a specific specialist. Communicate with referring physician offices as required to optimize patient care, decrease costs and increase patient satisfaction. Track these visits for High Risk population.
- Facilitate communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post acute care facility, and back to home. The Navigator will communicate with the primary physician, patient or care giver, and any transitional care staff that are available, such as Hospitalists, Case Managers, Social Workers, etc.
- Directly involved with the development and enhancement processes of the ACO with the aim to improve the clinical experience and satisfaction of services for referred patients and/or physicians.
- Become familiar with and utilize the services and programs in the community to support and assist patients at home.
- Monitor that appropriate home care, hospice and other ancillary services are in place and are being delivered as directed by the care team.
- Monitor and facilitate compliance with required quality measures for all ACO patients.
- Collect and report data as deemed necessary and by request of Supervisor to analyze possible gaps in care, focus on quality improvement processes and to track status of patient care.
- Attend required training and collaboration sessions as scheduled.
- Flexibility in work schedule to accommodate needs of patient and care givers.