Bilingual ACO Transitional Care Management - LVN Care Manager
Bilingual: English / Spanish ACO Transitional Care Management (LVN) CA LVN Licensure Required
Role Overview: The ACO Transition of Care Manager will work directly with patients participating in our Accountable Care Organization (ACO), focusing primarily on Transition of Care Management (TCM) and high utilizer management. This team member, an LVN (Licensed Vocational Nurse), will ensure seamless transitions for patients from acute care settings, reducing readmission risks, and providing personalized care to those identified as high utilizers. They will embody Vigilance Health's core values by being a partner in care, building solutions that drive patient outcomes, and coaching patients toward healthier lifestyles. CA Licensure as an LVN is required to perform the duties of this role.
Core Values:
Having Fire: Bring passion and energy to help patients navigate their care transitions, advocating for their health and addressing barriers that impact successful post-discharge outcomes.
Being Driven: Take initiative in identifying high utilizers, analyzing their healthcare needs, and designing proactive care plans to minimize unnecessary hospitalizations and improve patient wellness.
Being Partners: Collaborate closely with hospitals, primary care providers, and the patients care team to establish clear communication and support a smooth transition of care, ensuring all parties are aligned.
Building Solutions: Develop individualized care plans to address the unique needs of each high utilizer patient. Identify care gaps and leverage available resources to support patient well-being and continuity of care.
Being Coaches: Educate patients and families on the importance of follow-up care, medication adherence, and lifestyle changes that enhance health outcomes. Actively listen and provide guidance that empowers patients to engage in their care.
Essential Duties and Responsibilities: Conduct outreach to patients post-discharge to facilitate smooth transitions, ensuring they understand discharge instructions, have access to medications, and are scheduled for necessary follow-up appointments. Identify high utilizers of healthcare services and collaborate with their care teams to reduce avoidable hospital visits and enhance care coordination. Monitor and track key metrics related to patient outcomes, readmission rates, and high utilizer program effectiveness. Engage patients to assess social determinants of health, addressing issues such as transportation, housing, or access to food that may impact their overall health. Collaborate with other departments to ensure patients receive comprehensive, integrated care that meets their physical, mental, and social needs. Provide ongoing education and support to patients, empowering them to take an active role in their healthcare journey. Maintain accurate, concise documentation of all patient interactions, following established guidelines and protocols.
Key Performance Indicators (KPIs):
Readmission Rate: Reduction in hospital readmission rates for ACO patients within 30 days of discharge.
Patient Engagement: Number of successful patient contacts post-discharge and percentage of high utilizer patients actively engaged in care plans.
Follow-up Appointment Adherence: Rate of patients attending follow-up appointments within the recommended timeframe.
Patient Satisfaction: Positive feedback from patients regarding the support received during their care transitions.
GWC Framework:
Get It: Understand the complexities of patient transitions and the importance of proactive care management.
Want It: Be motivated to make a meaningful difference in patients' lives and reduce healthcare utilization through effective management.
Capacity to Do It: Possess the skills, experience, and empathy necessary to handle the responsibilities of this role effectively.
Bilingual: English / Spanish Required
This position is critical in ensuring that patients experience high-quality, continuous care, ultimately improving health outcomes and reducing unnecessary healthcare utilization. CA LVN Licensure is required to meet these responsibilities.
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