Population Health Resource Associate- AMH+ Tailored Plan Care Management

Overview

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 Resource Associate will implement, plan and coordinate 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. This work is done in conjunction with the Complex Care Team(s). Role will require home visits and face to face patient interaction.

Hours:

Monday
- Friday 9am-5:30 pm est, based on performance, role will switch to hybrid after first 90 days.

Provide outreach and care management support to patients; educate clients of available community resources. Assist clients with coordination of care between healthcare providers and other complex care team(s). Performs a range of non-clinical care management functions (outreach, health education, informal counseling, social support, resource linkages, interpretation/ translation, transportation coordination, and advocacy) for an active patient caseload to build individual and community capacity by increasing health knowledge and self-sufficiency and accurately documents activities with follow-up and plans of action.

Act as a client advocate and support the development of problem solving skills; provide instructions in basic health care procedures. Coordinate and/or participate in community health activities to include preparing patient education materials, brochures, bulletins, newsletters and other promotional materials and/or publications. Attend off-site, outreach education and recruitment sessions. Maintain liaison with other programs, offices and department sat Duke to coordinate program business and to accomplish program objectives.

Interface with external organizations as appropriate to ensure cooperative efforts are enhanced and available resources are utilized. Promote program on key coalitions and task forces to foster collaboration, educate constituencies, leverage resources, and reduce duplication of services. Monitor and evaluate program effectiveness, investigate trends, and recommend and implement modifications to improve program effectiveness. Prepare reports and conduct preliminary analyses setting forth progress and adverse trends.

Perform other related duties incidental to the work described herein. The work activity and patient acuity levels can create a stressful atmosphere. Additional responsibilities could include:

• Make home visits and other contacts with clients, as necessary.
• Coordinates regular practice visits and attends provider meetings to promote coordination of patient care.
• Serves as liaison to health/social services providers to build and maintain effective relationships with physicians, site leadership, hospital staff and other community stakeholders to ensure timely and appropriate patient follow-up.

• Provides regular oversight (including accompaniment into the field) of new hires and completes required performance adherence to program standards and implements improvement and development plans as needed.
• Utilizes leadership principles to mobilize team to achieve positive outcomes.
• Conduct follow-up on outstanding matters to ensure they are successfully resolved.
• Represents program interests at internal and external meetings.
• Collect and analyze key statistics (disease registries, biometrics, care management productivity, etc.) to ensure adherence to established care management protocols and benchmarks and investigates methods for improving service delivery.
• Complete chart reviews and facilitate peer review process among assigned staff members.
• Utilizes data to implement individual and program-level performance improvement activities (standardization of care, establishment of disease and population health metrics, consistency of reporting, information flow and management, job functions).
• Assess training needs of new and existing staff,…