This job was posted by https://joblink.delaware.gov : For more information, please see: https://joblink.delaware.gov/jobs/1244326

Job Summary:

The LPN Care Coordinator works in collaboration and continues partnership with chronically ill or high-risk patients and their family/caregiver(s), clinic/hospital/ specialty providers and staff, and community resources in a team approach to:

• Promote timely access to appropriate care.
• Increase utilization of preventive care.
• Reduce emergency room utilization and hospital readmission.
• Facilitates health and disease patient education.
• Increase comprehension through culturally and linguistically appropriate education.
• Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
• Supports patient self-management of disease and behavior modification intervention.
• Facilities patient medication management based upon standing orders and protocols.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.

Essential Responsibilities:

• Serve as the contact point, advocate, and information resource for patients, care team, family/caregiver(s), and community resources.
• Work with patients to plan and monitor care:

_o Assess patients unmet health and social needs.\ o Develop a care plan with the patients, family/caregiver(s) and provide (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).\ o Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.\ o Create ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time._

• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.

Work setting:

• Clinic
• In-person
• Office
• Outpatient