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Population Health Coach RN - Med Surg

Company: CHI Saint Luke's Hospital at the Vintage
Location: Houston
Posted on: January 27, 2023

Job Description:

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 initiatives.

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 health.

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 on.

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 well-managed patients.

6. Identify and implement case plans that are patient centric. Communicate with patients using the patients preferred method of communication.

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 care.

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 practices.

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 needs.


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) preferred
* 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 interpersonal skills.
* 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.

Physical Requirements:

* Sitting upright in a comfortable position with frequent opportunity to move about. May be required to lift light

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Keywords: CHI Saint Luke's Hospital at the Vintage, Houston , Population Health Coach RN - Med Surg, Healthcare , Houston, Texas

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