- Identifies the targeted high risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
- Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
- Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
- Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
- Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
- Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
- Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
- Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
- Provides telephone triage and advice, patient education, and direct patient care.
- Provides functional supervision of assistive personnel.
- Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
- Maintains required documentation for all care activities.
- Works with practice and PO/PHO leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
- Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
- Participates in Quality Improvement projects collaborating with the Quality Team at the unit level on Quality Initiatives for the Health Center.
Nursing Specific Info
Required qualifications must be met by the candidate in order to be interviewed and considered for the position. Posting may be filled after the initial 5-day posting period.
Salary & Nursing Framework Level:
This UMPNC RN posting is posted as Nursing Framework REG NURSE - LEVEL C (B INC).
Actual Nursing Framework LEVEL and salary will be determined at time of hire.
Nursing Framework levels range from Level A to Level E.
Applicants who have left the UMPNC bargaining unit must include on their resume dates of past employment including months and years of service along with effort. Positions less than 20 hours/week may be combined.
If you have questions regarding this posting or would like assistance with nursing opportunities please contact Nurse Recruitment at (734) 936-5183.
This position is covered under the collective bargaining agreement between the U-M and the Michigan Nurses Association and the U-M Professional Nurse Council union, which contains and settles all matters with respect to wages, benefits, hours and other terms and conditions of employment.
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act.
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
U-M EEO/AA Statement
The University of Michigan is an equal opportunity/affirmative action employer.