Team Care Member provides prescribed medical treatment, personal care and education services to ill, injured, convalescent and disabled persons in such settings as hospitals and/or doctor’s office. Team Care member play a major role in care management implementation of patient-centered medical home concepts, including involvement in quality improvement teams and PCMH workgroups. Need skills and experience in motivational interviewing or at least readiness to learn the skills.
Triage incoming patients by obtaining vital signs, reconcile current medication list, reconcile allergies and determine chief complaint.
Assist physicians with examinations, minor surgeries, diagnostic procedures and treatments.
Provide basic patient care as ordered.
Phone triage, patient scheduling, calling pharmacies. Authorize refills. Respond to tasks, patient messages. Print medication list/call select patients, reconcile medication lists.
Assist with specialty clinics:
Process Mirena, Paragard, Implanon/Explanon requests. Talk to patients, answer questions and schedule appointments. Send letter and follow up as needed.
Administer injection of medications or immunizations in accordance with approved nursing protocols. Observe patient for any reaction to medications or immunizations, treatments and significant incidents.
Respond to life threatening situations based upon nursing standards, polices, procedures and protocols.
Prepare exam rooms for patients, restock supplies, sterilize instruments and maintain medical equipment.
Maintain knowledge of all office procedures: ECG, “in-house” labs, spirometry, administration of nebulizer treatments, insertion and monitoring of IVs, Holter Monitor, assistance with minor surgical procedures and GYN procedures.
Appropriately document all nursing interventions in the electronic medical record. Review the chart for completeness, test results and billing.
Scan upcoming appointments for additional medical record information necessary. Obtain medical records from other physician offices, hospitals, labs, emergency rooms, and radiology departments prior to patient visit.
Complete all “tasks” assigned to individual team (as well as covering for other nurses who may be temporarily absent), including responding to patient messages, prescription refills, lab results, referrals, home health agencies, medication prior authorizations, patient forms and follow up from physicians. All tasks must be reviewed, addressed and marked appropriately before the close of each business day.
Respond to questions from patients, family members, faculty/residents, other health care providers in a timely and professional manner. Patient phone calls should be answered on the same day they are logged in, before leaving for the day. If patient is not home at the first attempt, a notation should be made in the medical record. All patient conversations must be documented in the electronic medical record.
In their roles as team members in the Patient Centered Medical Home, nurses are also asked to administer and collect patient satisfaction surveys, contact patients in between visits to assess medical status and medication adherence, and perform Medicare Annual Wellness Assessments for the patients on their individual teams when not assisting a provider in clinic. Patient education: may include diabetic teaching, home monitoring, coagulation therapy, discharge medication reconciliation, drug assistance programs, nutrition and barriers to care.
Participate in all staff meetings, education lectures and PCMH/QI improvement activities.
Follow EVMS protocols related to infection control, environmental safety and patient confidentiality. Complete annual recertification for OSHA, Blood Borne Pathogens, Compliance, Respiratory FIT and IT policy. Maintain current CPR certification and nursing license.
Nursing staff is required to fill in for other clinical staff during vacations and illness.
Team care member participates in Pre Visit
Chart selection of following days patients scheduled visits by patients presenting with:
Review of charts
Enter orders for indicators due based upon standing orders
Team Care member participates in Post Visit
Provide care plan from visit to include:
Review providers plan of care by problem and confirm written record of pt goals
Schedule Preventive/screening tests
Referrals including: TMT, vasectomy, minor surgery, gyn clinic (provide IUD
packet for Mirena, discuss procedure for colpo, CDE referral, Podiatry,
Reviewing diabetic flow sheets
Teaching self glucose monitoring and insulin administration
Coordination of transitions of care from the hospital to LTC
Communication with continuity providers
Team Care member participates in SENIORS CLINIC
Family counseling to include:
Functional mood and Cognitive assessments
Coordination of transitions of care from hospital to LTC
Must be a licensed LPN in Virginia. One year experience preferred.