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Geriatric Care Coordinator

Amoskeag Health

Amoskeag Health, formerly Manchester Community Health Center (MCHC), is a nonprofit 501(c) (3) federally qualified health center offering high-quality, comprehensive, and family-oriented primary health care and support services since 1993. Now known as The Dr. Selma Deitch Center for Children and Teens, Child Health Services (CHS) is the original pediatric practice of MCHC dedicated to improving the health and well-being of at-risk children. In June of 2019, all locations of MCHC consolidated under one name, Amoskeag Health.

Through all its programs, Amoskeag Health serves over 14,579 patients annually across four locations in Manchester.

Mission
To improve the health and well-being of our patients and the communities we serve by providing exceptional care and services that are accessible to all.

Vision
We envision a healthy and vibrant community with strong families and tight social fabric that ensures everyone has the tools they need to thrive and succeed.

Core Values
We believe in:
• Promoting wellness and empowering patients through education
• Fostering an environment of respect, integrity and caring where all people are treated equally with dignity and courtesy
• Providing exceptional, evidence-based and patient-centered care
• Removing barriers so that our patients achieve and maintain their best possible health

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

Primary care, preventive care, outreach and enabling services at Amoskeag Health are supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Health Center Cluster grant number H80CS00571. This grant provides approximately 15% of total revenue.


The Geriatric Care Coordinator (GCC) will support patients aged 65 and over in meeting their health goals, living their best life and managing their chronic conditions. The GCC works in collaboration and continuous partnership with chronically ill or “high-risk” elderly patients and their family/caregiver(s), the Amoskeag Health integrated care team, specialty providers and staff, and community resources. This position assists in the development of patient-centered care plans that are based on evidenced-based practices and protocols, assesses patient needs and abilities and implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status and ensuring the delivery of quality, efficient, and cost-effective health care services. This is a 40-hour per week, exempt position. 

  1. Assesses patient’s unmet health and social needs.
  2. Develops a care plan with the patient, family/caregiver(s) and providers that increases patient’s ability for self-management and shared decision-making.
  3. Maintains accurate and timely documentation in the electronic medical record of assistance and services provided.
  4. Registers appropriate patients in the Chronic Care Management program, completing related paperwork with patient, and submitting charges for billing when allowed by third party payers or grant funding.
  5. Meets with program patients on a monthly basis for review of overall status, medication adherence and progress on health goals. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.
  6. Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
  7. Coordinates timely patient access to appropriate medical and specialty providers. Supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding care transitions and referrals.
  8. Facilitates and attends meetings between patient, family/caregiver(s), care team, payers, and community resources as needed. Makes home visits to patient’s home as necessary.
  9. Works to increase patient utilization of preventative care, and reduce emergency room utilization and hospital readmissions.
  10. Increases patient and family comprehension of care plan by providing culturally and linguistically appropriate education and care. Assists in building patient and family/caregiver’s health literacy skills and ability to navigate services and resources independently.
  11. Tracks patient progress on self-management goals and progress with service coordination efforts for high-risk patients and facilitates transition of patients to the Practice Care Team Nurse when appropriate. Documents care and progress in Amoskeag Health’s electronic medical record (EMR).
  12. Collaborates on the development of workflow, procedures, processes, and data collection to include key metrics for department performance, billing and grant reporting.
  13. Identifies current and potential relationships with referral agencies and maximizes those relationships.
  14. Provides clear written and oral communication to both Amoskeag Health patients and employees.
  15. Attends and participates in meeting requirements of Amoskeag Health and funding sources. This may include, but is not limited to assisting with development, implementation and monitoring of grant proposal.  If absent, responsible for reading of minutes and signing the documentation.
  16. Works autonomously and is accountable for responsibilities. Requests input, feedback, and clarification whenever necessary to facilitate positive working relationships with supervisor, providers, other staff, and community resources.
  17. Reviews the current literature regarding effective care coordination, effective engagement and communication strategies, care management strategies and behavior change strategies and incorporates into clinical practice and day to day department efficiency and care excellence.
  18. Attends mandatory safety-related and infection control in-services as designated by Senior Management.
  19. Other responsibilities as assigned by supervisor and Senior Management.
Requirements:
  1. Education/Training: Bachelor’s Degree in Social Work, Human Services, Nursing, or equivalent experience required.  
  2. Experience: Three (3) years of community health and/or case management experience preferred. 
  3. Must possess an understanding of grant related requirements and be responsible for reporting and clinical tracking.
  4. Knowledge/Skills: Ability to work with technology such as computers, smart phones and/or tablets
Job Location:

Manchester

Date Added: January 13, 2022

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