Collaborates closely with primary care offices throughout Jefferson to apply the PCMH model, in order to improve care coordination, in accordance with appropriate quality improvement (Lean, Change Agent, etc.
March 15, 2020
Works with patients to develop an individualized care plan that includes short and long-term goal setting, with a particular emphasis on social needs, barriers to care, behavioral health support, medication management, and chronic disease self-management.
May 16, 2020
Completes non-clinical surveys and education to assigned participants and engages them into programs, completes non-clinical interventions to meet member needs and identifies and refers candidates who require complex interventions to other programs/resources utilizing established criteria and documentation processes.
May 23, 2020
Develop project related deliverables with minimal to moderate supervision including project plans, PowerPoint presentations, status reports, meeting minutes, issue/risk logs, and meeting facilitation documents.
May 29, 2020
Monitor implementation and progress of various projects including, working closely with the Center for Population Health groups and colleagues, Partners entities, Partners IT, eCare, and others as need.
June 04, 2020
Participates as a key member of the FHCN health center innovation team in the development, implementation and evaluation of population health, quality and practice transformation strategies.
June 22, 2020
Reviews cases with the providers, nursing and medical assistant staff as needed, seeks expert advice on issues for clients and provides input to providers, nurses and medical assistants on client response.
June 23, 2020