General Responsibilities:
- Assess and re-evaluate patient needs utilizing information from EHR and additional tools as appropriate to determine patient needs and preferences and communicate those to all treatment participants
- Create an Integrated Care Plan in conjunction with the patient and/or caregiver
- Ensure the patient understands the Care Plan and is equipped to follow it
- Identify and address all barriers that might impede the ability of the patient to care for themselves
- Assemble appropriate team of professionals to assist in meeting patient needs, organize patient care activities and share information among all participants
- Assist the patient/caretaker in navigating the health system while addressing any insurance coverage issues
- Update assessment and care plan at least every 90 days
- Utilize the Integrated Care Plan to drive all activities and services
- Provide information and feedback in daily Huddles regarding needs, plans/interventions/results
- Research ways to meet needs and put action steps in place, monitor for progress
- Advocate on behalf of the patient
- Follow up regularly with patient to ensure needs are being met and identify any changes to patient circumstances, any compliance concerns
- Consult with treatment team when noncompliance is found
- Provide training on disease management and healthy living skills
- Provides initial Diabetes Care Introduction
- Provide support and education for patient and their support system
- Facilitate securing/providing medical records when patient is in the hospital, ED, etc.
- Track and support patients when they obtain services outside the practice.
- Follow-up with patients within a few days of an emergency room visit or hospital discharge.
- Communicate test results and care plans to patients/families.
- Collaborate and consult with staff members and outside sources in the delivery and arrangement of services
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
- Effectively demonstrates the application of adult specific competencies
Supervision and Consultation:
- Seek supervision and consultation as needed
- Accept and employs suggestions for improvement
- Actively works to enhance skills
Clinical Record Keeping:
- Document in a timely fashion per AltaPointe policy
- Document in a clear and concise manner.
- Document legibly
Courteous and respectful attitudes towards consumers, visitors, and co-workers:
- Treat patients with care, dignity, and respect
- Respect privacy and confidentiality
- Assist others as needed
- Adopt a teamwork approach with coworkers
Administrative and Other Related Duties as Assigned:
- Actively participates in Performance Improvement activities
- Actively participates in AltaPointe committees as required
- Completes assigned tasks in a timely manner
- Follows AltaPointe policies and procedures
- Attends appropriate in-services training and other workshops