Website Borrego Health
Participates as an active dedicated member in the Health Homes Program focusing on populations with complex needs. Assisting in integration of whole-person care with goals towards meaningful data collection and improving the health and well-being of the targeted population. Be proactive in the integration of Behavioral Health services into the Primary Care setting. Responsible for managing care for patients who have multiple health and social issues and need information, effective clinical therapy, patient activation, emotional support and self-management support. Engaging providers and the patient in the essential components of Primary Care and Behavioral Health Services at a particular clinic site. Is responsible to work with the Patient, Primary Care/Specialty Providers and Behavioral Health Providers to set clear treatment goals for the patient and engage in interventions with specific goals and strategies. Accomplishes a Treat-to-Target based plan that includes data driven care planning and systematic case review meetings. Is responsible for patient enrollment into the Health Homes program and follow-ups as needed based on the treatment plan.
Essential Duties and Responsibilities:
- Log-in and maintain current information in the EHR, Program Registry and i2i referral tracking systems.
- The Care Manager is a registered nurse who frequently serves as patients’ primary
point-of-access to the Care Management Team.
- Works with patients to identify health/wellness goals and incorporates these goals into shared care plans that facilitate communication among patients and providers.
- Facilitates and ensures recommendations are communicated across the health care team.
- Engages in treatment team meetings to provide PCP teams insight into patient specific wellness goals, symptoms and diagnoses, and background information.
- Participates in systematic population caseload review and partners with other members of the Integrated Care Management Team to ensure physical, behavioral, and social health services are requested and provided to the patient as part of the culturally sensitive whole-person care.
- Monitors patient schedules for the Health Homes patient population in coordination with Care Coordinators, Behavioral Health Care Managers and Community Health Workers.
- Review new and refill prescriptions with the providers and the patient to maintain updated records.
- Assist patients in monitoring medication refills in a timely manner.
- Verify that the patient has enough medication until the next visit.
- Maintain a medical record for each Health Homes patient.
- Records shall be complete, orderly, up to date, and correctly filed
- Track Health Homes patient population data in the medical record and assists in duplication of the data in the e registry.
- Obtain appropriate confidentiality release from patient when warranted.
- Obtain records of previous mental/behavioral health treatment as requested by providers.
- Verify signatures and dates on all forms in the medical record.
- Monitors Telemedicine appointments for Health Homes population.
- Maintains Telemedicine documentation in patient medical record.
- Confirm consents are signed for each telemedicine visit for the Health Homes population.
- Other Duties as Assigned
- Performs regular patient screenings and vitals.
- Engages patients and supports/encourages patient activation towards achievement of health goals.
- Provides evidenced-based practices such as Motivational Interviewing.
- Tracks medical and behavioral health outcome measures in a patient registry, including but not limited to BP, BMI, HBa1C, PHQ-9, and GAD-7 scores.
- Uses outcome measures to synthesize treatment plans for patients.
- Care managers systematically outreaches to the patients in between face-to-face appointments with the patient and engages them on self-management goals and activities.
- Care Manager engages with a patient (weekly, bi-weekly or monthly based on tier designation by Health Plan) for every patient in their assigned population, and documents all efforts appropriately.
- Provides patient and family education about chronic medical and behavioral health conditions to improve health literacy.
- Gathers input from other Care Management Team members to prioritize patient cases for systematic population/caseload review.
- Provides quality care to the patients of Borrego Health, within the scope of practice outlined by state or federal law.
- Delivers care in accordance with established standard of care and accepted community standards.
- Understands the organizations commitment to provide high quality integrated patient care.
- Promotes a patient centered environment.
- Other duties as assigned.
- Diploma from an approved High School or GED Equivalent
- Licensed as a Registered Nurse in the State of California.
- Experience: Previous experience in the medical field and /or, in the Behavioral Health /Mental Health field is preferred.
- An understanding of Behavioral Health as associated with Chronic Medical Diseases preferred.
- An understanding of the Biological and Physiological nature of Mental Illness Diseases preferred.
- An understanding of, or ability to learn payor sources.
- All staff that is presently working within a clinic is required to have a Current and Valid CPR