Population Health Specialist- Rising Risk

Duke Connected Care
, a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and its surrounding areas.

The Population Health Specialist will develop, implement, and evaluate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy and training services, in an effort to enable their recovery or management of complex, chronic health conditions. The Population Health Specialist is responsible and accountable for supporting clinical expertise for specific complex patient populations. This role will perform supporting clinical disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc.

The Population Health Specialist functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community. Patient base consists of patients who are sub-optimal users of healthcare and/or management of chronic disease.

Identify any barriers to proper utilization and determine best steps for following treatment recommendations, as well as providing resource/benefit education, counseling and self-care processes. Focus on improving transitions in care for patients, physicians, family and community. The Population Health Specialist will work as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care.

Assess patient's condition, locate appropriate treatment and resources, ensure continuity of care and document treatment progression; provide individual counseling sessions concerning rehabilitation treatment and health maintenance. Document interventions within medical record system(s) to collaborate with health care providers and monitor treatment programs. Assess the overall health and health education needs of the patient. Review patient data related to disabilities or medical limitations and maintain liaison with primary health care provider.

Participate in multi-disciplinary teams to promote a healthy context or social environment; developing and supporting local partnerships to broaden the local response to health inequalities and advocate for patient acting in support providers. Review and evaluate Admission, Discharge and Transfer (ADT) electronic alerts, electronic medical record notes or other patient trend data. Use communication systems and telephone consultation in order to ascertain needs of identified patients.

Conduct community, telephone and practice encounters with patients and other care management team members to identify care plans, barriers and goals. Follow-up with patients and providers on identified health care needs and identify possible resources to address those concerns and/or work with care management team to address concerns in a multi-disciplinary method. Facilitate and manage referrals from referral specialist, providers, and other care management staff to ensure that identified red flags and healthcare needs of patients are addressed.

Provide individual consults to patients on health education issues. Develop the health awareness of individuals, as well as groups and organizations, empowering them to make better health choices. Provide specialized treatment, implementation of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures. Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community.

Address the total needs ofthe individual: medical, psychosocial, behavioral, and spiritual. Monitor access to care, services, and treatment including linkage to the medical home. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Use proven processes to measure patient?s understanding and acceptance of the proposed plan(s), willingness to change, and support to maintain health behavior change.

Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness. Document and communicate with all provider(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care - generally from hospital to home or community facilities. Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).

Determine patient care plan using data from multiple sources…