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 23, 2020
Complete integrated care plans to promote collaboration with physical health providers and system partners.
June 26, 2020
Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishes appropriate timelines for achieving identified goals.
July 14, 2020
Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO and the complex care management program.
July 20, 2020
Maintains collaborative, team relationships with peers, colleagues and affiliated establishments in order to effectively contribute to the organizational goals and to help foster a positive work environment.
July 23, 2020
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.
July 29, 2020
Supports an integrated care model tapping into appropriate resources both internally and external to the organization required.
September 15, 2020
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.
September 23, 2020
Participates in performance improvement activities utilizing performance improvement principles to support and improve patient care.
September 29, 2020
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.
October 02, 2020