Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishes appropriate timelines for achieving identified goals.
December 09, 2022
Facilitate care coordination with external entities including behavioral and physical health providers, Targeted Case Management (TCM), Transitions, Integration and Partnerships (TIP) Unit, Housing providers, Courts and Probation, Child Welfare, and School District of Philadelphia.
February 01, 2023
Facilitates cooperative and collaborative relationships among the various disciplines and departments to ensure effective quality patient care delivery with the PCP and post-acute providers.
March 03, 2023
Participates in performance improvement activities utilizing performance improvement principles to support and improve patient care.
March 16, 2023
Complete integrated care plans to promote collaboration with physical health providers and system partners.
March 28, 2023
Meets regularly with leaders at the local clinical and community service sites (Primary Care, BH, ED, inpatient), nurse manager, and administrative manager to triage program issues appropriately.
March 30, 2023
Supports an integrated care model tapping into appropriate resources both internally and external to the organization required.
April 25, 2023
Provide daily oversight of an assigned panel of high-need candidates/members, delivering interventions designed to reduce unnecessary emergency department (ED)/emergency room (ER) and inpatient (IP) utilization, increase connection to primary care/behavioral health care, and demonstrate improved health outcomes for the served population.
May 18, 2023