Job Description
Job Description Primary Accountability The Care Coordinator coordinates the provision of patient care within the Health Home Program (HHP) to ensure the patients' care is continuous and integrated amongst service providers, as well as supports the Care Coordinator Manager in the implementation of the HHP. There will be responsibility for the navigation of the patient's health, behavioral health, social systems, community resources, and housing transitions. There will be collaboration with patients and their family members, health-care team members, and outside organizations to reduce or eliminate barriers to care. Description of Primary Responsibilities Support patient centered, continuous and consistent care, ensuring that an assigned Home Health Program (HHP) patient receives access to needed services identified through the assessment process. Coordinating, maintaining and servicing panels of patients with special service needs, as determined by the Health Home Program and stratification process. Working with the patient to implement their Health Action Plan (HAP). Assisting the patient in navigating health, behavioral health, and social services systems, including housing and transportation. Sharing options with the patient for accessing care and providing information regarding care planning. Identifying barriers to the patient's treatment. Monitoring and supporting treatment adherence (including medication management). Assisting in attainment of the patient's goals as described in the HAP. Encouraging the patient's decision making and continued participation in HHP. Accompanying patient's to appointments as needed. Monitoring referrals, coordination, and follow ups to ensure needed services and supports are offered and accessed. Sharing information with all involved parties to monitor the patient's conditions