-
Accountable for developing,
facilitating services, and
partnering with community resources
to address the needs of an assigned
population
-
Develop and facilitate services that
provide education, screening, and
advanced assessments for assigned
population throughout the continuum
of care
-
Consult with other community
agencies and committees to identify
potential resources for resolving
clients health, psychosocial, or
financial problems
-
Function as a liaison to external
agencies and shares information to
others, which may impact care and/or
services of clients
-
Perform other appropriate duties as
assigned. (ex. Disaster relief and
other community based promotion
activities.)
-
Use
independent, professional judgment
to provide case management services
to assigned population
-
Accurately identify and prioritize
at risk patient population
-
Collaborate with patient,
caregivers, physicians, and other
providers to develop a comprehensive
plan of care
-
Assure implementation of care plans
throughout the continuum of care to
include a variety of settings (i.e.
home, school, work site, clinic)
-
Effectively communicate care plans
and other client-related activities
both verbally and in writing to
appropriate personnel and agencies
-
Communicate with physicians and
other health care team members
regarding necessary changes to care
plan that promote optimal medical,
academic, and behavior performance
-
Demonstrated ability to use
teaching, learning, and counseling
skills
-
Promote empowerment of patient in
self-management of disease
-
Coordinate and develop educational
opportunities/programs related to
assigned population for a variety of
stakeholders (ie the healthcare
system, school system, community,
employers, health departments
patients and their families
-
Develop and conduct educational
opportunities/programs that promote
best practice in the management of
various populations
-
Serve
as preceptor/evaluator for various
disciplines
-
Coordinate primary and secondary
prevention opportunities that
promote early identification and
intervention for various populations
-
Provide leadership in population
based health improvement
-
Develop and implement programs or
projects which facilitate the
attainment of corporate goals
-
Lead
and/or participate in
interdisciplinary team meetings
-
Responsible for the development of
strategic long range plans in the
area of specialization
-
Participate in the replication of
program services throughout the
region and state by providing
opportunities to increase the
knowledge of population-based health
initiatives
-
Participate in the development and
coordination of marketing efforts
-
Use
principles of disease management to
facilitate improvement in patient
outcomes
-
Maintain and advance knowledge and
skills in areas of specialization
-
Utilize advanced skills and
assessments to work autonomously in
the hospital, school, outpatient,
and/or community settings
-
Participate in professional
organizations
-
Advance clinical expertise through
attendance at conferences, reading
journals, etc.
-
Utilize advanced assessments to
evaluate and communicate
effectiveness of comprehensive plan
of care
-
Maintain a professional network
among colleagues
-
Demonstrated knowledge and skills
necessary to provide service
appropriate to the age of the
patient
-
Promote and participate in quality
improvement (QI) activities and
clinical research
-
Change practice behavior as a result
of data
-
Encourage clinical problem
identification and resolution
activities
-
Identify, address, and report
quality issues identified through
data sources
-
Identify and participate in research
activities through data analysis and
collection.
