Responsible for assisting patients referred to AHS for assistance in accessing and utilizing health care resources due to their complex chronic illness and cooccurring psychiatric diagnoses Improves health outcomes through coordinating care educating patients building trust between patients and medical practitioners and enhancing communication and the continuity of care Teaches counsels and monitors patients on health issues relevant to their care Consults with other health care team members to coordinate the services of patient education preventive care and disease management Principal Accountabilities 1 Performs care coordination for highrisk patients to ensure continuity of care and quality healthcare delivery across the care continuum2 Utilizes established clinical pathways to facilitate comprehensive and consistent chronic disease specific condition education3 Maintains patient confidentiality with all activities in the Care Coordination Program4 Provides care coordination by collaborating with a multidisciplinary team5 Promotes patient adherence to individualized plan of care6 Collaborates and communicates patient findings to primary care provider Care Coordination Team and healthcare providers and identified carepartners as appropriate across various health care settings via timely accurate and clear communication modalities7 Utilizes evidencebased riskstratification tools to proactively assess chronicallyill population identify patients at risk for diseaserelated sequelae and deliver patientcentered evidencebased interventions to prevent future progression or exacerbation of illness8 During exacerbation intervenes at the earliest opportunity through multidisciplinary collaboration with all members of the care team including patient and identified carepartner to return the patient safely to optimal level of healthfunction in an optimal setting9 Identifies opportunities for health promotion and disease prevention Identifies SocialBehavioral Health needs which impacts patients outcomes and appropriately refers to Social Work team member10 AssessesRefers patients to available community support services as deemed necessary11 Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population12 Assesses the selfcare needs of the highrisk patient and identifies need for additional support Provides patientcarepartners education regarding preventionrecognitiontreatment of disease exacerbation and promotes selfmanagement of chronic condition and comorbidities13 Participates in evidencebased research performance improvement and quality initiatives as appropriate14 Assumes responsibility and accountability for professional development and pursues ongoing continuing education to deliver patientcentered care Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements15 Assists in orientation and training of new staff as requested Participates in provider outreach and education Serves as a community resource providing educational programs for the community16 Collaborates with AHS leadership on additional tasks as requested
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