Care Coordinator-Vaccine Confidence and Wellness Outreach

Clark Fork Valley Hospital Plains, Montana
coordinator health community care coordination coordination patients team family education items management communication coach
December 20, 2022
Clark Fork Valley Hospital
Plains, Montana
Location: Plains SUMMARY The employee will have a primary focus of community outreach, spearheading vaccine education efforts that ultimately increase general vaccine knowledge, confidence in, and use of vaccines as a part of one's overall health and wellness. The employee will also work with other care coordination team members to coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. They also Facilitate a "share goal model" within and across settings to achieve coordinated high-quality care that is patient- and family-centered. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned, particularly those that foster effective care transitions. Vaccine Confidence and Wellness Outreach Items: Outreach to CFVH staff, public health, EMS, school staff, faith-based community and other key influencers to address concerns and promote the importance of receiving appropriate vaccinations as part of overall health. Public education: Collaborate with our key stakeholders (as identified above) to facilitate community conversations about vaccine efficacy and reliability, with an emphasis on sharing scientific data as well as feedback from respected neighbors and friends. The goal here is to build trust and challenge the underlying causes of vaccine hesitancy. Promotional campaign: Work with our marketing department to utilize brochures, flyers, social media and our website to highlight vaccine availability and promote its importance. Access: Develop programs to facilitate access to vaccinations which may include supporting transportation or using home health personal among other possibilities. Care Coordination: Expand our Care Coordination program to specifically identify those patients in our service area with care gaps related to vaccination and target them for outreach from a nurse and/or social worker to address their concerns and encourage their receiving appropriate vaccines. Care Coordination Items: Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population. Implement an effective internal tracking system for identified patients. Coach patients/families toward successful self-management of their chronic disease. Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care. Assess patient and family's unmet health and social needs. Provide effective communications to improve health literacy. Develop a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time. Promote healthy behaviors in all populations and ensure navigation assistance with community resources. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records).Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed. Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other NRACO Care Coordinators and Coach).Assist with discharge planning from Clark Fork Valley Hospital. EDUCATION and/or EXPERIENCE Current licensure as a RN or LPN required. The following items are required of the successful candidate: Demonstrated evidence of essential leadership, communication, education, collaboration, and counseling skills. Proficiency in communication technologies (email, cell phone, etc) Effective organizational skills and demonstrated ability to maintain accurate notes and records. Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers. The following items are preferred of the successful candidate: Previous experience in caring for chronic disease patients. Three to five years' experience in clinical or community health settings. Previous Care Coordination, Case Management, or Home Health experience. Previous

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