o Manages patient populations, including care transitions.
o Uses adult learning principles to facilitate behavior change and patient empowerment.
o Collaborates with patient, caregivers, and providers to develop a comprehensive plan of care.
o Utilizes motivational interviewing to support patient self-management skills.
o Supports medical home and care coordination principles; follows/completes assigned activities/protocols.
o Participates in data collection/monitoring and formulation of process improvement plans.
o Conducts comprehensive assessments that identify behavioral, clinical, social, and environmental concerns and the needs of patients.
• Demonstrates sound clinical judgment. o Monitors patient's response to interventions and plans care appropriately.
o Identifies educational needs of patient/family and provides instruction/referrals to meet self-management goals.
o Identifies priorities and organizes work accordingly.
o Follows evidence based practices and standards of care.
• Planning/Consultation o Serves as an expert clinical leader within ambulatory clinics.
o Functions as a change agent using effective communication skills.
o Develops productive relationships with leaders, physicians, staff and community partners.
o Works collaboratively with other care team members to influence positive patient outcomes
o Supports team based care model.
o Maintains a case load consistent with program guidelines.