SHS-RN CARE FACILITATOR-CENTRALIZED CARE

General Purpose of Job:

As part of a larger population health strategy, the Care Facilitator will play an integral role in the larger ambulatory care management redesign for Sparrow Medical Group (SMG) practices, acting as both a liaison to their locally assigned clinic, while also taking on a new role as a centralized resource within the Population Health Service Organization (PHSO). This position will require someone who is extremely adaptable and can juggle coverage in a local practice, and help create the roles and responsibilities of a newly developed internal team.

Common Duties and Responsibilities:

While the essential duties will remain the same while working onsite in a practice, the remote (centralized) work within the PHSO will be new for the larger health system. The team will be exploring opportunities to coordinate low-to-moderate risk transitional care management (TCM) outreach, implementing standardized social determinants of health (SDOH) screening, and will be seeking support to potentially oversee a small group of staff in the future.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Provides Self-Management education and support to care team members patients and families
• Educates and supports appropriate care team members in patient self-management support concepts and techniques
• Actively works with patients to use self-management goal-setting techniques and develop action plans to encourage self-care
• Assisting the patients and/or families in recognizing and prioritizing the problems that need to be addressed
• Providing support to help patients and/or families cope with the disruptions and distress associated with managing their illness and empowering them to regain control of their life, carry on normal roles and activities, and manage the emotional impact of their illness
• Problem solves with patients and their families to maximize their ability to follow preventive, remedial and/or rehabilitative recommendations
• Provide individual or group counseling / coaching as appropriat
• Educates and supports office staff in providing Care Coordination
• Develops and maintains an effective professional working relationship with all patients, families, physicians /providers and health care team members
• Develops and maintains an effective professional working relationship with specialists and facilities (including hospitals, home health care and other ancillary providers) with which SMG physicians have ongoing relationships
• Coordinates care with payer case manager for patients with complex or catastrophic conditions
• Develops, recommends and implements a plan, in conjunction with the patient, family and health care team, which addresses the problems and needs identified in the assessment
• Provides or arranges chronic disease education (as appropriate) for patients and families as needed
• Provides consultation services for other department staff
• Assists in developing a process to track care coordination activities
• Assists in developing written procedures and/or guidelines on care coordination processes and trains appropriate care team members on the processes
• Facilitates follow-up with patients discharged from the hospital or Emergency Department as needed to assure patients understand self-care and treatment expectations and are seen in primary care offices on a timely basis
• Educates and supports office staff in performing a comprehensive assessment
• Screens selected cases to identify needed services and interventions to deliver quality comprehensive care that addresses the patient's full range of health care needs
• Identifies issues, which may impact medical outcomes based on a comprehensive assessment that may include the patient's medical condition, support systems, finances, living situation, housing, behavior, cognition, function and abilities, and the patient's choices and preferences
• Works with office staff as part of an Interdisciplinary Team, develops and implements a plan which addresses problems and needs identified in the assessment and ensures continuity of care by:




• Assisting patient and family with access to appropriate resources and services based on a thorough knowledge of community resources and eligibility requirements
• Advocating on behalf of patients and their families with internal/external resources and payers for needed services, including negotiating with insurance companies for non-covered benefits
• Communicates with patients, families, members of the health care team and others in a professional, diplomatic and empathetic manner
• Provides clear, concise, timely written documentation on the patient's medical record and on departmental records




• Collaborates with other members of the Sparrow Health System (SHS) departments to collect analyze and utilize data for quality / process improvement
• Participates in activities, which support and advance the department and SHS's mission, vision and goals to improve outcomes and operations
• Attends mandatory department and SHS meetings or training sessions
• Provides or arranges education for patients, families, physicians and other members of the health care team, to enhace patient care or improve department outcomes and operations
• Acts as the initial point of contact (POC) for the centralized team, as the group researches and implements new workflows to support the embedded Care Facilitators
• Supports the development of new policies/procedures to ensure documentation is in place for the remote work
• Reviews payer requirements and acts as the Subject Matter Expert (SME), as the PHSO reviews opportunities to expand the support staff
• Works closely with the Business Intelligence/Information Technology (BI/IT) team to create new dashboards and track internal productivity
• Pilots potential programming related to TCM, SDOH, Employee Health outreach and other areas of opportunity utilizing a structured Plan, Do, Check, Act (PDCA) framework