Medical Home Care Coordinator
CurrentResponsible for the logistical support across all patients in a pediatric primary care office, as well as the clinical monitoring of high risk patients in need of more intensive care management. Promotes interdependent collaboration between the patient, physician, healthcare team, and family in an effort to improve and maintain the patient's social, emotional, functional, and physical health status throughout the continuum of care. Support chronic disease management through establishing routine contact with PCP, facilitating specialist referrals, connections with community resources, and helping to close gaps in clinical care and ensure smooth transitions of care. Encourage clear communication amongst patients, families, caregivers and the care team through integrated care planning, team meetings and collaboration with community-based agencies. Support patients identified at greater risk for poor outcomes including management of multiple barriers to reduce avoidable admission to a hospital setting and developing care plans addressing social, financial, and behavioral barriers. Coordinate appropriate follow-up for patients and families following a transition of care, such as a hospital admission or discharge, emergency room visit, or specialist visit. Communicate and affirm patient needs, plan of care, and changes in status with the healthcare team and the patient and family. Research and coordinate community-based resources, services, and supports available to patients and their families; build relationships using effective communication strategies with families, schools, specialists, and other community professionals and resources.