HHHN Mission

To provide the best health care, and access to that care, for everyone in our communities

HHHN Vision

To pioneer an innovative, sustainable and community-focused health system through comprehensive primary care and diverse partnerships

Proposed Schedule: 40 hours per week. Monday-Friday from 8am-4:30pm

Position Summary

The LPN Care Manager position serves a multifaceted role within the Homeward Bound/Palliative Care (HWB/PC) team. In addition to providing clinical support, the LPN Care Manager provides administrative support as well as support to patients under the direction of the Interdisciplinary Team (IDT) including the RN Care Manager, providers, and Director of Population Health Programs, using a team approach to patient care. Strong clinical and administrative, computer and phone support skills are required along with a desire and aptitude to assist providers and staff with direct patient care, including the ability to provide phlebotomy services in patient’s homes, as needed. The LPN Care Manager will work closely with community partners, develop and coordinate access to resources for patients/families and assist with transitions of care from various settings. Additionally, this position will provide excellent patient care in a compassionate, caring, culturally and ethnically sensitive manner that promotes the organization’s mission, vision, and core values.

Essential Duties and Responsibilities:

• Answer phone calls, create patient cases, and communicate with all HWB/PC team members, external partners, and other HHHN staff

• Coordinate with HWB/PC team for scheduling of patients for home visits, virtual visits, group Grandpad visits and phlebotomy services

• Lead the Interdisciplinary Team (IDT) Meetings

• Responsible for documenting and coordinating with external partners to follow patients through transitions of care

• Work with discharge liaisons at local nursing homes and hospitals during transitions of care to assist with coordination of services, setup home visits, and inform the team of transition plans

• Assist patients/families with access to resources to address any barriers to care, help with coordination of services and work with HWB team to ensure patients receive such services

• Follow-up with all Homeward Bound (HWB) patients that have been discharged from the emergency department, hospital, or rehabilitation/nursing home within 48 hours via phone, telehealth or home visit when necessary

• Create and promote adherence to a care plan developed in coordination with the patient, primary care provider, RN Care Manager, and family/caregiver(s)

• Increase patient’s ability for self-management and shared decision-making

• Review the patient’s health history to include pertinent preventative, social and past medical conditions; use available resources for patient education and follow-up care per provider orders

• Review lab results with patients/caregivers and provide instructions under the direction of the provider

• Coach patients pertaining to red flags and follow plan of care directed by Provider and/or RN Care Manager

• Adhere to standards, policies and procedures for diagnostic and point of care testing, including specimen collection, quality assurance, documentation in the electronic medical record and patient education. This may include transportation of biological or other medical materials for IDT team members

• Lead and operationally oversee Grandpad deployment, patient programing and focus on improving socialization through the Grandpad for improvement in patient outcomes

• Maintain annual LPN competencies and required clinical continuing education

• Enthusiastically serves on various departmental initiatives that support the Mission, Vision and Core Values

• Willingness, if not already certified in Phlebotomy, to provide patient blood draws or specimen collection in the patient’s home

• Coordinate and schedule home draws in coordination with the IDT team members, partner organizations and patient needs

• Order necessary supplies to perform all necessary home lab draws or specimen collections

• Coordinate with Glens Falls Hospital on any lab needs or requirements for necessary testing and results

• Maintain credentialing, training, and any necessary policy requirements to perform phlebotomy services

• Perform additional duties and special projects as assigned

  Qualifications:

• Unrestricted current LPN license to practice nursing in New York State.

• Must possess a certificate from an accredited school of nursing.

• 2+ years as an LPN preferred

• Current BLS Certification

• Well organized with demonstrated ability to manage multiple tasks and prioritize workload

• Proficient computer competencies including Microsoft applications and Electronic Medical Record experience preferred

• Ability to work independently, as a team member, and with patients/caregivers/families through verbal and written communication providing excellent customer service

• Must have excellent telephone skills, be able to manage challenging conversations, and maintain calm under pressure

  The pay rate for this position is $28.00/hour.