Licensed Practical Nurse - Community Outreach - Full Time

Description Summary : Under the direction of the Director of Coordinated Care, the Care Partner provides culturally appropriate support and information to the patient and their family in a series of structured visits and follow-up phone calls in a variety of settings that may include the patient's home. The Care Partner will have knowledge of resources in the community to assist in patient referral. The Care Partner assists patients in their understanding of how to use healthcare and other appropriate resources to improve their overall quality of life. The Care Partner uses a holistic and interdisciplinary approach to care management and health promotion. The Care Partner builds relationships with the patient, family, other healthcare providers and the community. Facilitates patient rights. The Care Partner consistently exhibits behaviors set forth in the organization' mission, vision and value statements. Responsibilities : Identifies and communicates with potential patients of specialty Transitional Care needs : Runs daily reports to review for any potential inpatient candidates requiring specialty transitional care on discharge to include but not limited to patients Re-admitted within 30 days, patients without a Primary Care Physician and patients without and / or limited payor source. Visits patients that were Re-admitted within 30 days and conducts interview to identify potential causes for readmission. Visits patients without a Primary Care Physician and assists in the establishment of a PCP Visits with indigent patients and performs initial clinical history and needs assessment to ascertain potential needed resources. Discusses needs with patient and educates about available resources. Assists patients in finding and understanding how to use a medical home (the medical home being the physician or clinic the patient chooses for accessing primary care) Facilitates followup appointments with the next level care provider Follows care pathways (evidence-based steps) designed and selected to deal with patient's specific health, social concerns and problems. Maintains organization of follow-up file of patient needs. Monitors and follows up with patients as needed either by telephone contact or in person. Documents appropriate activities through appropriate record keeping. Maintains appropriate chart documentation. Educates patients and their families in healthy lifestyles and promotes healthy behavior changes. Empowers and prepares patients to manage their own care. Encourages patients to set goals, identify barriers and challenges to assist in monitoring their own conditions. Reduces cultural and socio-economic barriers between patient and their healthcare providers. Maintains and supports patient rights by honoring patient choice and educating them on rights to discharge. Performs job in a professional manner : Effectively communicates with all patients, associates and healthcare providers. Maintains confidentiality. Attends educational opportunities as indicated. Dresses in appropriate professional attire. Performs other job duties as indicated. Team player works well with others. Dependable in attendance and productivity. Engages in department and organizational initiatives Attends department and administrative meetings Behaves in a professional manner. Requirements : Knowledge of computer skills including data entry, Word and Excel required. Excellent communication skills required. Five years, nursing practice, in hospital facility or occupational health nursing. Graduate from a school of licensed practical nursing. Current Louisiana license by Louisiana State Board of Nursing is required. CPR required. BLS required Work Schedule : 8AM - 5PM Monday-Friday Work Type : Full Time