Lpn Care Coordinator

Job Summary:

The LPN Care Coordinator works in collaboration and continues partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/ specialty providers and staff, and community resources in a team approach to:

· Promote timely access to appropriate care.

· Increase utilization of preventive care.

· Reduce emergency room utilization and hospital readmission.

· Facilitates health and disease patient education.

· Increase comprehension through culturally and linguistically appropriate education.

· Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).

· Supports patient self-management of disease and behavior modification intervention.

· Facilities patient medication management based upon standing orders and protocols.

· Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.

Essential Responsibilities:

· Serve as the contact point, advocate, and information resource for patients, care team, family/caregiver(s), and community resources.

· Work with patients to plan and monitor care:

-Assess patient’s unmet health and social needs.
-Develop a care plan with the patients, family/caregiver(s) and provide (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
-Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
-Create ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.

· Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.