Description

The Care Coach demonstrates an advanced understanding of the coordination of care to patients that is directed towards chronic disease management as outlined and approved by the patient’s Primary Care Provider (PCP) Plan of Care (POC) and provides patient counseling/coaching/education over the phone, working toward increasing the patient’s health literacy. Communication will be purposeful and goal-driven based on the Solvera Health Care Coach model. The Care Coach provides care that reflects initiative and responsibility indicative of professional expectations, under the supervision of a registered nurse or physician. The Care Coach is required to be at least an LPN (Licensed Practical Nurse)

The Care Coach reflects the mission, vision, and values of Solvera Health, consistently practices the “hospitality in healthcare” philosophy, and adheres to high standards of customer care.

PRIMARY RESPONSIBILITIES

• Provides direct communication to the patient under the supervision of the Program Manager or physician based on the POC; consults with other members of the patient health care team as required or outlined by the Solvera Health Care Coach model policies and procedures. Evaluates patient responses and works with the patient to set goals for disease management.
• Communicates with Program Manager and patient care team members about patient's clinical condition(s), disease management, POC, compliance, etc. including results of diagnostic studies as needed to provide care.
• Acts as a patient advocate and active care team member as an extension of the Primary Care Provider
• Notifies licensed personnel when patient requests/requires clinical nursing judgement.
• All communication with a patient is to include and consider their needs specific to the standard of care for the patient's age and health literacy starting level.
• Performs all aspects of patient communication in an environment that optimizes patient safety and reduces the likelihood of confusion in relation to chronic disease management.
• Communicates appropriately and clearly to coworkers, licensed personnel, physicians, and physician office staff.
• Treats patients and their families with respect and dignity; identifies and addresses psychosocial, cultural, ethnic and religious or spiritual needs of patients and family.
• Interacts professionally with patient and family and involves patient and family in patient coaching/counseling/education to help not only families cope with a patient's chronic diseases, but also to improve relationships and understanding between the family and patient.
• Documents patient care information and maintains an accurate medical record in accordance with current standards and policies for all communications and interactions with patients and their families, licensed personnel, physician, and physician office staff.
• Maintains privacy and confidentiality of all protected health information at all times in accordance with HIPAA regulations
• Complies with all organizational policies and procedures and acts according to ethical business standards to complete assigned tasks.
• Maintains a virtually safe, comfortable, and therapeutic environment for patients and families in accordance with the company tone and model.
• Manages and operates equipment correctly, with care, and allows its functionality to be used for work purposes only; performs preventative maintenance as needed.
• Provide appropriate responses to the patient, staying in control with a calming demeanor in emergency or physically stressful situations.
• Performs other related duties as assigned or requested by Supervisor or Program Manager.

PROFESSIONAL qualificationS/ SKILLS

• Licensed Practical Nurse minimum degree
• Health care field experience preferred
• Advanced skills and ability to operate computer/technical equipment
  • Excellent verbal and written communication skills. Answers telephone calls in a professional manner; directs calls appropriately; refers patient needs to office physician.
• Exceptional interpersonal skills in order to maintain a good working relationship with all staff members of the organization.
• Compliant with regulatory requirements for Medicare Services, state and federal regulations and standards
  • Demonstrates the ability to be flexible, organized, including the ability to function effectively under stressful situations.
• Completes training sessions as assigned and returns documentation in a timely fashion
• Attends annual review and departmental training sessions, as scheduled and assigned
• Attends staff meetings
• Participates actively in performance improvement and continuous quality improvement (CQI) activities
  • Demonstrates knowledge of the principles of family dynamics over the life span and the knowledge necessary to provide age-appropriate information to the patients served.

Additional Key Functions

• maintains Resource Schedule for Care Coach team to ensure adequate staffing to cover patient needs
• Provides direct training to new Care Coach team members in the standards of patient care and established protocols and procedures.

PHYSICAL DEMANDS

On-the job time is spent in the following physical activities:

• Prolonged, extensive, or considerable sitting
• Minimal physical effort
• Manual dexterity and mobility
  • Ability to perform routine repetitious tasks on a continuous basis and perform these tasks regardless of frequent interruptions, such as repetitive hand movements; grasping, pushing/pulling, fine manipulations
• Vision and hearing adequate to perform essential functions
  • Contact with customers under wide variety of personal circumstances