p>Provides patient support for preventive maintenance and chronic disease management of the following departments/programs/individuals: • Assesses patients emotional status, cognitive status, and learning readiness within the patients environment to augment the holistic plan of care • Collaborates with community resource persons to deliver services that promote quality outcomes and continuity of care • Assumes the patient advocacy role to identify and resolve issues with in the healthcare delivery system • Collaborates routinely with primary care provider and interdisciplinary team regarding patients progress and changing needs • Effectively utilizes nursing process to manage patients with chronic diseases • Effectively provide education to patient and families to meet specific disease related goals • Collaborates with internal performance leaders and value based program leaders to support, implement, review, share and submit performance metrics • Effectively utilizes disease registries to identify patients with gaps in care • Provides safe patient transitions and hand offs through effective communication with patient, family, and RN or other care provider • Demonstrates accountability by serving as a team member providing coaching/mentoring/training applicable staff as a nurse.
Works with the clinical team and manages the disease registries by identifying and following up with patients not meeting clinical goals, based on evidenced-based, approved Clinical Practice Guidelines.