CHT Care Coordinator

JOB SUMMARY: As a member of the Community Health Team, the Dietitian Care Coordinator works with patients to identify their health goals and together with their practitioners create a care plan that will support them in achieving their goals. The Dietitian Care Coordinator provides healthy lifestyle counseling, medical nutrition therapy for chronic conditions, and/or short-term case management for high-risk, socially and medically complex patients. This role helps identify and manage unmet needs of the patients to ensure appropriate resources are in place to improve health outcomes.

FUNCTIONS and RESPONSIBILITIES

1. FUNCTIONS and RESPONSIBILITIES
   1. Provides patient and family education and support in removing barriers to achieve wellness and management of chronic conditions, provides patients/families with educational materials for self-management that are both paper and web-based.
      1. Will perform duties within scope of practice per license and follow standards of practice as outlined by, but not exclusive to:
         1. The Commission on Dietetic Registration for Registered Dietitians.
         2. The American Association of Diabetes Educators and the National Certification Board for Diabetes Educators for diabetes educators.
      2. Will keep up to date on the current standards and best practice recommendations as outlined by the respective governing board.
   2. Coordinates patient care with members of the integrated health care team.
      1. May use reports or reporting systems to identify high-risk patient populations.
      2. Collaborates with cross-departmental teams and/or members of partner agencies to develop care plans.
         1. Actively participate in multiorganizational care teams and case reviews to provide patients with wrap-around care coordination through diverse community resources.
         2. Be a clinical resource to non-clinical members of the care team.
      3. May use electronic communication to communicate about patient needs with members of the CHT and other appropriate agencies following all organization and HIPAA policies and procedures to improve care coordination.
      4. Will use a patient-centered approach, including motivational interviewing, on developing care plan.
   3. Provides care coordination for medically and socially complex patients.
      1. Meets with patients to assess and identify any unmet health needs.
      2. Connects patients to community supports.
      3. Works closely with health care practitioner to develop plan of care.
      4. Assure that the patient and all appropriate team members are engaged in the implementation of agreed upon plan(s), and that each understands the responsibilities for his/her part of the plan.
      5. Follows up with patients through face-to-face, telephone and/or portal contacts in order to facilitate support to achieve self-management goals.
   4. Participates in required departmental activities
      1. Attends mandatory staff meetings and committee meetings as deemed appropriate by Director of Community Health Integration.
      2. Completes work assigned accurately and in timely manner.
      3. Demonstrates collegiality and commitment relevant to the mission of Lamoille Health Partners and the CHT.
      4. Maintains absolute confidentiality of all patients’ records, medical treatments, and diagnoses, and abide by all LHP policies and procedures.
      5. Completes documentation and data tracking as relates to duties.
      6. Assists in training new team members in areas of expertise including care coordination models and tools and proper documentation practices.
      7. Contributes knowledge and skills to team projects.
   5. Participate in quality initiatives and workflow development as designated by the Director of Community Health Integration in collaboration with the Director of Quality.
      1. Participates in Patient Centered Medical Home (PCMH) accreditation process.
      2. Works closely with all staff members to perform rapid-cycle testing of initiatives in the form of Plan-Do-Study-Act (PDSA) model and other quality projects.
      3. Population health strategy development and implementation.
      4. Develop and implement care conferencing and team-based care structures.
      5. Advise on other clinical and care management workflows.
      6. Serve as a Superuser as needed and other duties as assigned.
   6. Communicates regularly with Practitioners, nursing staff, and Practice or CHT members to prioritize care coordination needs of the patient population.
   7. Completes all Electronic Medical Record (EMR) and other documentation as required---daily, weekly, and monthly.
      1. Has a working knowledge of clinical systems.
      2. Uses clinical information to identify areas for improvement.
      3. Assists in monitoring office processes to identify areas for improvement; recommends areas for improvement to the leadership/patient care team, and assists in treatment planning for patients.

QUALIFICATIONS

• Education
  1. Nutritionist and/ or Diabetes Educator
• Experience
  1. At least two years of experience as a dietitian providing nutrition education, ideally in a healthcare setting
• Knowledge and Ability
  1. Must maintain a high level of confidentiality
  2. Strong computer and organizational skills are essential, as well as the ability to multitask, respond to shifting priorities, and to work well under pressure while meeting all required deadlines.
  3. Ability to work independently while demonstrating the skill to work positively within the framework of a team.