Population Health Coach RN - Med Surg
Company: CHI Saint Luke's Hospital at the Vintage
Posted on: January 27, 2023
Population Health Coach RNOverview
Baylor St. Luke's Medical Center is an 881-bed quaternary care
academic medical center that is a joint venture between Baylor
College of Medicine and CHI St. Luke's Health. Located in the Texas
Medical Center the hospital is the home of the Texas Heart--
Institute a cardiovascular research and education institution
founded in 1962 by Denton A. Cooley MD. The hospital was the first
facility in Texas and the Southwest designated a Magnet-- hospital
for Nursing Excellence by the American Nurses Credentialing Center
receiving the award five consecutive times. Baylor St. Luke's also
has three community emergency centers offering adult and pediatric
care for the Greater Houston area.
Provide care management across the health care continuum for
members within the CIN and ACO. Serve as an integral member of the
health care team as well as the CIN department team who works to
ensure safety, best practice and high quality standards of care are
maintained. Coordinate a wide range of self-management support and
disease registry activities for members. Navigate patients through
the healthcare delivery system (inpatient, outpatient, ambulatory
settings) for patients actively needing/ seeking care and will also
engage patients who have been identified as needing interventions
but not yet actively seeking assistance from their provider. Work
with physicians, group practices, PODs and clinical inpatient and
outpatient and staff in various settings to address specific
quality improvement/performance improvement initiatives.
Collaborates with the CIN Population Health Coach team on
system-wide quality improvement/performance improvement
1. Work with "at risk" members and families on Self-Management
Support, such as, but not limited to: setting short and long-term
goals for self-management of chronic disease; addressing medication
adherence in patients not meeting outcome goals, working with
members to create a plan for health behavior change; performing
individual needs assessment, care plan design, documentation and
implementation, and evaluation of outcomes; communicating a plan
for healthcare needs between physician/office visits; providing
needed patient education; and reducing of preventable hospital
admissions, re-admissions, excessive therapies, DME, etc.
2. Engage patients at the point of care (Inpatient and clinic
settings) and establish a relationship/case plan that continues
outside of the point of care with the primary goal of improving
patient health as the patient and their physician define
3. Set clear expectations for patient responsibilities, support
patient self-management in recovery, and establish feedback loops
between patients and providers to identify complications early
4. Proactively identify solutions to promote low acuity utilization
before complications become high priority.
5. Leverage data to identify changes in the health status of
6. Identify and implement case plans that are patient centric.
Communicate with patients using the patients preferred method of
7. Follow evidence-based care pathways, coordinating care across
multiple provider sites, and ensure patients follow recommended
recovery care plans.
8. Collaborate with CHI TX Division providers and staff within
their offices/clinics. Focus on cultivating collaborative working
relationships with all community providers who interact with our
patients with the goal of providing patient centric care.
9. Collaborate with healthcare providers in the community not
affiliated with CHI TX Division. Focus on cultivating collaborative
working relationships with all community providers who interact
with our patients with the goal of providing patient centric
10. Actively Participates in Quality activities, such as, but not
limited to: strategies to achieve individual clinic level quality
and efficiency goals, and working with healthcare team in the
development of tools for optimal patient outcomes and report
findings. Participate in workflow committees to develop best
11. Identifies opportunities for improvement (at individual, clinic
and CIN levels) and actively Works with healthcare and CIN team to
correct or improve results.
12. Maintains latest skills and knowledge related to the job.
13. Performs other duties as assigned to meet the organization`s
Education and Licensure Required:
* Associate's Degree preferred
* Registered Nurse (RN)
* Healthcare Coach Certification or Certified Care Manager (CCM);
or obtained within three (3) years of hire
* Basic Life Support (BLS) through American Heart Association (AHA)
* Proof of completion of Mandatory Reporter abuse training specific
to population served within three (3) months of hire
Minimum Experience Required:
* Five (5) years of clinical and case management/health coach
experience required, (Care Management, Utilization Management, ER,
ICU also acceptable)
Minimum Knowledge, Skills, and Abilities:
* Must have strong organizational (time management) and
* Ability to handle multiple priorities.
* Must possess strong customer service skills to coordinate
services. Must have effective communication, telephonic skills.
* Computer skills to include navigating complex reporting software
and Microsoft Office.
* Ability to articulate care plan and patient needs to providers.
Ability to identify patient self-directed care plans.
* Sitting upright in a comfortable position with frequent
opportunity to move about. May be required to lift light
Keywords: CHI Saint Luke's Hospital at the Vintage, Houston , Population Health Coach RN - Med Surg, Healthcare , Houston, Texas
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