Disease Management Nurse - Manager

Disease Management Nurse

Essential Functions :

• Work with leadership to develop and implement structured disease management programs, starting with self-measured blood pressure. Future programs will focus on diabetes, asthma, and potentially other chronic disease states, such CHF and COPD.
• Track and respond to patient referrals, meeting patients in-person and virtually to enroll in program. Instruct patients in use of self-monitoring equipment, medication adherence strategies, and lifestyle strategies for self-management
• Manage onsite devices and relationship with DME vendor(s) to provide devices to patients
• Receive and review telemonitoring results
• Provide patient education regarding their medication regimen, medication adherence strategies, dietary strategies for self-management, physical activity strategies for management and appropriate lifestyle changes such as smoking or alcohol cessation, sleep hygiene or weight management
• Work with patients to develop SMART goals around chronic disease self-management, using motivational interviewing techniques and supportive coaching to assist patients in achieving goals
• Conduct proactive outreach to patients at scheduled cadence to check in on self-monitoring and medication adherence, goal progress, and assess for any barriers, issues or concerns
• Serve as intermediary between patient and provider to troubleshoot barriers, issues and concerns between visits
• Flag and review out-of-range readings with provider, work with provider to titrate meds between visits adhering to established nurse-driven protocols, educate patient on regimen changes and ensure new meds obtained
• Field incoming calls from enrolled patients
• Work with Director of Clinical Informatics and Quality Measures and Director of Care Management and Population Health to track and report program data
• Work with Director of Care Management and Population Health to develop templates to document program data in EHR
• Participate in meetings related to HCCN-wide initiatives and grants around chronic disease self-management programs
• Work with marketing team and registered dietician to develop patient-friendly, health literacy-forward print educational materials AND vet pre-made educational resources (stoplight tools, CDC Diabetes Prevention Program (DPP) curriculum, etc.)
• Develop Spectrum library of demo devices, including BP cuffs, demo BG monitors, demo insulin pens and administration pads, demo inhalers
• Provide one-off education for patients with new chronic disease diagnoses or new medications needed to manage those illnesses (inhalers, insulin syringes or pens, nebulizers, glucometers, CGMs)
• Work with clinical nursing team to orient to demo devices, educational materials, meds, self-monitoring equipment so that they can also provide face-to-face education to patients being seen for visits
• Work to obtain free, gently used equipment (i.e. refurbished nebulizers, loaner blood pressure monitors) for distribution to patients with insurance barriers to obtaining equipment
• Other duties as assigned

Qualifications :

Preferred Experience :