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HHHN Mission

To provide the best health care, and access to that care, for everyone in our communities.

HHHN Vision

To pioneer an innovative, sustainable and community-focused health system through comprehensive primary care and diverse partnerships.

Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm

Position Summary

The Pathways Care Manager is an integral part of the Homeward Bound and Palliative care team, enhancing coordination and providing an array of services to the patients enrolled in the program. These services include but are not limited to: coordination, coaching, transfer of self-management skills, and addressing barriers (including socio-economic). Guidance will be provided to the patients and families for the purpose of improving the health of our populations, improving the quality of care provided and decreasing overall costs. The Pathways Care Manager will work alongside the providers, and health center team to assist with meeting the needs of the Homeward Bound and Palliative care patient population. This position will also serve as a back-up to the Homeward Bound Palliative Care Coordinator.

Essential Duties and Responsibilities:

+ Provide outreach, information, guidance, and education to the patient and/or family, primary care providers and other members of the care team for appropriate healthcare utilization, chronic disease (e.g. diabetes, hypertension) self-management skills, effective care transitions, assessment and elimination of barriers, including socio-economic barriers, promoting wellness and preventative care measures and enhanced patient-provider communication

+ Provide coaching, information, and referral services to patients managing various chronic health conditions on-site at the health center, via telehealth, and/or in a home setting

+ Identify and address gaps in care and/or services to provide relevant community and/or health care resources

+ Refer, coordinate, provide access to and aid in obtaining resources which address barriers to receiving care, and follow up with patients/families

+ Communicate plan of action and results to patient and/or family members and assist in identifying and resolving barriers to care as appropriate.

+ Act as a patient advocate as appropriate, including timely follow up to ensure situations have improved and evaluation of service efficacy.

+ Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence.

+ Build and maintain efficient and effective relationships among medical staff and other care team members, including outreach to community resource/organizations that support a positive outcome for patients.

+ Answer phone calls, create patient cases, and communicate with all HWB/PC team members, external partners, and other HHHN staff

+ Work with discharge liaisons at local nursing homes and hospitals during transitions of care to assist with coordination of services, setup home visits, and inform the team of transition plans

+ Follow-up with all Homeward Bound (HWB) patients that have been discharged from the emergency department, hospital, or rehabilitation/nursing home within 48 hours

+ As needed, coordinate provider schedules for home visits and/or outpatient palliative care services

+ Attend and participate in general staff meetings/trainings as needed

+ Arrange referrals to medical specialists, Public Health and other agencies for patients as indicated by the other health care team members

+ Aid in development of tracking tools to advance the program and maintain for reporting

+ Participate in quality improvement activities for the program

+ Participate in Interdisciplinary Team meetings and weekly case review

+ Actively contribute to the professional development, morale and teamwork of staff while presenting a positive attitude and patient-minded vision, with patient satisfaction as the constant goal; uphold our core values of Quality, Appreciation, Creativity and Sustainability

+ Other duties as assigned

Qualifications:

The requirements listed below are representative of the knowledge, skill and ability to perform the essential functions:

+ Bachelor’s Degree in a health or human service field, applied professional experience in case (care) management and/or social work required. Will consider an equivalent combination of experience and education

+ Experience working in fields of Health care, behavioral/mental health, substance/alcohol abuse preferred

+ Must have a valid driver license and be able to travel throughout the Network

+ Must have strong verbal and written communication skills

+ Proficient computer competencies including Microsoft applications, electronic medical records and related databases

+ Must be well organized and can effectively manage multiple cases and projects

+ Must be self-directed, detail-oriented and motivated

+ Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships

The pay rate for this position is $24.48/hour.