DOTHOUSE MISSION STATEMENT

To be an essential resource for our community in its efforts to achieve the highest levels of health, well-being and quality of life for its residents. To provide affordable, accessible, and exceptional health care and other essential services in an environment that respects our consumers, our staff, and our diverse community. To be a leading force for change in the health, economic, and social status of our community.

SUMMARY:

The Complex Care Manager works with patients enrolled in complex care management (CCM) services to improve coordination of care and health outcomes through the development and implementation of patient-centered care plans and collaboration with multidisciplinary care team members.

GENERAL DUTIES & RESPONSIBILITIES:

Complex Care Management

- Identify patients at highest risk for health deterioration, sentinel events, and/or poor outcomes, through assessment during health education sessions, review of the DotHouse Adult High-Risk Registry, and referrals from primary care providers or other care team members.

- Collaborates with other care team members, including but not limited to the PCP, Clinical Pharmacist, Nutritionist, Behavioral Health and Case Management teams to ensure coordination and continuity of care

- Complete comprehensive assessments of new care management patients and work in collaboration with the patient, caregiver(s)/family, and care team members to develop patient-centered care plans that incorporate each individuals’ treatment goals, strengths, and barriers.

- Coordinates with outside organizations and community partners such as VNA agencies, caregiver programs, DME providers, social service agencies, and external care managers (insurance-based, etc.).

- Coordination of patient transitions to or from outside care facilities and/or providers to prevent related complications.

- Check in with CCM patients regularly, both in-person and telephonically, per CCM protocol.

- Provide motivational interviewing and facilitate patient empowerment, self-management, and participation in care-related decision-making.

- Advocate for the patient when necessary to ensure they receive care that is safe, effective, patient-centered, timely, efficient, and equitable.

- Create and maintain patients lists to track stages of CCM status (eligible, enrolled, etc.)

- Follow CCM workflows and document all patient contact and related coordination per CCM protocol and in compliance with applicable reimbursement and regulatory guidelines.

- Compile and share community-based resources with other care team members to support overall improvement in patient care at DotHouse.

- Support DotHouse in maintaining status as a patient-centered medical home by ensuring compliance with standards and guidelines in the domain of Care Management and Support.

- Participate in ongoing CCM program development, improvement, and evaluation.

- Perform other duties as required.

REQUIRED SKILLS & COMPETENCIES:

Experience:

· Experience in care management, home health care nursing, hospital nursing, or primary care.

· Experience working with vulnerable patient populations, preferably including diverse, safety-net

populations

· Education: Registered Nurse (minimum)

· Clinical expertise in conditions prevalent in safety-net populations, such as chronic diseases (diabetes,

HTN), substance use disorder, mental illness, etc.

Skills:

• Able to perform comprehensive health assessments and develop patient-centered care plans
• Well-versed in-patient engagement and behavioral change strategies, including motivational interviewing.
• Able to manage complex caseload – strong organizational, time management, and creative problem- solving skills.
• Excellent interpersonal skills and ability to work collaboratively
• Ability to work independently with minimal supervision and as part of a team
• Strong written and verbal communication skills
• Computer skills including electronic health records, Microsoft Excel, Word, and PowerPoint