The Beaches Health and Wellness Program, a working model for reducing inappropriate emergency room utilization for a regional geography of Duval County, provides the additional human resources needed to ensure patients are served within a primary care medical home, receiving the health education needed to address chronic conditions like diabetes, cardiovascular disease, COPD, and other conditions that impact quality and years of life. This program provides enrolled patients with additional supports needed to address barriers to care and to encourage healing on their road to wellness.
The target population for this intervention includes uninsured adults being discharged from Baptist Beaches Hospital inpatient stays with specific diagnosis of chronic condition(s) best addressed in primary care to reduce the chance the patient will need future hospitalization or emergency room support. The project includes a network of partners based in the area, with a full-time RN Case Manager and a Community Health Worker. These two staff members work in tandem to address both clinical care and health education along with coaching, home visits, and assessment of the social determinants of health, with an action plan to reduce barriers and increase self-advocacy / empowerment to address health conditions. The patient enrollment period averages one year, though no patient is left behind should they struggle or experience new challenges along their journey.
Key to the program is meeting each patient bed-side in the hospital as part of comprehensive discharge planning with the hospital social work team and the RN Case Manager. This factor builds the rapport and trust needed to see patients successfully engage in post-hospitalization care. Before discharge, the RN Case Manager establishes a follow-up appointment with a primary care provider and health education / coaching session appointments to assist the patient in determining their next steps.
Essential duties and responsibilities
- Develop, implement, and coordinate disease management, primary care, and behavioral health referral plan as part of inpatient hospitalization discharge planning for uninsured patients with chronic disease diagnosis and / or those requiring wound care follow-up - Collect, triage, and assess client information pertinent to client’s history, condition, and self-management skills regarding chronic disease management to develop a comprehensive, individualized care plan that promotes wellness, appropriate primary care utilization, and cost-effective care and services. - Monitor and evaluate appropriateness of evidenced-based care management plan, protocols and collaborative practice, assess progress toward meeting goals, and modify the plan to help achieve desired outcomes. - Maintain data and outcomes on patients through WeCareJax electronic medical records database and/or other tools to measure program outcomes (in concert with program evaluator). - Under the supervision of a primary care provider in the community health setting, provide direct patient services (such as post-discharge wound care) as appropriate to support patient and program goals. - With hospital partner(s), establish regular schedule of patient rounds to identify uninsured patients prior to discharge to initiate follow-up care plans in accordance with program goals and appropriate standards of care for discharge planning / care transitions to the community health setting. - Initiate/maintain relationships and develop resources necessary to achieve a health safety net for uninsured, low-income patients in the catchment area served. In addition to medical partners, this network will include social, housing, nutrition, and emergency financial services agencies in the area. - Will travel locally between care settings to meet with patients in hospital or to support follow-up care plans in the patient’s primary care medical home. MAJOR FUNCTIONS - Perform concurrent assessment of clients referred from area hospitals, discharge planners, and social services. - Incorporate knowledge of mortality, morbidity, and established standards of evidenced-based practice associated with chronic disease, behavioral health, and acute hospitalization. - Serve as primary resource to patient, family members, health care providers and their support staff for questions and concerns related to the health plan and in navigating through the health system issues. - Within a partner ambulatory clinic setting, provide follow-up wound care support as part of the patient discharge plan when indicated. - Conduct scheduled community outreach services in collaboration with community partners, hospitals, and special groups. - Perform other duties as assigned.
- Excellent assessment skills and knowledge of uses and side effects of commonly prescribed medications. - Experience in conducting client education in chronic disease and working under established protocols. - Self-starter and ability to function independently in a community health setting. - Comfortable with initiating protocols, maintaining community relationships, and seeking resources for patient outcomes. - Ability to establish and implement protocols with providers to better serve patient care. - Strong desire to enhance patient and communities’ knowledge of health issues and to work with low income and homeless patients.
Education and Experience
- Direct nursing experience for at least five (5) years. Hospital, home health, or primary care setting preferred. - Licensure/registration/certification requirements: RN unrestricted licensure in the State of Florida; Basic Life Support (BLS) and Certified Diabetes Educator (CDE) preferred - Obtained a Bachelor’s Degree in Nursing at minimum - Knowledge of data entry and database utilization; proficient with computer programs including Excel and Word. - Experience documenting care within an electronic health record system; Athena Health preferred.