RN Health Coach
Company: St. Joseph's Health
Posted on: January 7, 2021
- We, St Joseph's Health and Trinity Health, serve together in
the spirit of the Gospel as a compassionate and transforming
healing presence within our communities.
- To be world-renowned for passionate patient care and
outstanding clinical outcomes.
- In the spirit of good Stewardship, we heal by practicing
Justice in fostering right relationships to promote common good,
Reverence in honoring the dignity of every person, Excellence in
expecting the best of ourselves and others; Integrity in being
faithful to who we say we are.
The Nurse Coach will identify and carry a caseload of patients with
chronic or complex diseases and/or high utilization patterns;
independently provide support to patients in transitioning across
the continuum of care by providing nurse assessment and care
planning, education, coordination and consultation; track
individual and population based outcomes.
--- Identify high-risk patients through a review of
population-based and individual patient information.
--- Provide a baseline patient assessment of patient activation and
knowledge, wellness, health behaviors, clinical condition and
--- Develop a patient care plan to include patient goal, education
targets, social supports needed, and recommendations for the
clinical care team.
--- Provide individual and group education and coaching that
activates patients to enable them to make knowledgeable health
decisions and participate more fully in their care.
--- Identify transitional care gaps and coach patients to access
--- Identify needed community and medical services to support
patients' goals and coach patients to access them.
--- Identify clinical care improvements that could support patients
in achieving activation and health goals.
--- At the physician's direction, work to modify clinical care
plans to support patients in achieving activation and health
--- Facilitate modification to clinical care plans through the
clinical care team.
--- Support patient navigators by providing clinical advice and
patient communication, where appropriate.
Outcomes Assessment and Tracking:
--- Maintain patient registries to identify patients at risk and
--- Track changes in patient activation, health behaviors and
clinical outcomes and, identify and implement appropriate
--- Provide population-based summaries of outcomes.
NYS Registered Nurse. Bachelor's prepared in nursing or other
clinical field, or clinician with bachelor's or master's in
education, health services or related field. Minimum of two years
of experience in primary care, patient coaching or outpatient case
management, etc. Candidates must demonstrate at least one year in
providing patient/family education. Training in the Care
Transitions Intervention or Transitional Care models a plus.
Experience in collecting and utilizing population-based data to
identify patients and prioritize interventions preferred.
Successful candidates will have excellent interpersonal skills to
work effectively with patients and the members of the clinical care
team. They will take the initiative to ensure clinical care and
related support services are made available to patients. They will
also have the ability to think critically and creatively about what
is needed to improve patient activation and health improvement.
Successful candidates must be excellent educators and be able to
empower patients. Successful candidates will need to be able to
function independently in a fast-paced environment, prioritizing
responsibilities and multitask.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
WORK ENVIRONMENT AND HAZARDS:
Office/Clinical setting. Exposure Class 1.
Light work: standing, walking, sitting and lifting
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of
hospitals and hundreds of health centers in 22 states. Because we
serve diverse populations, our colleagues are trained to recognize
the cultural beliefs, values, traditions, language preferences, and
health practices of the communities that we serve and to apply that
knowledge to produce positive health outcomes. We also recognize
that each of us has a different way of thinking and perceiving our
world and that these differences often lead to innovative
Trinity Health's dedication to diversity includes a unified
workforce (through training and education, recruitment, retention
and development), commitment and accountability, communication,
community partnerships, and supplier diversity.
Keywords: St. Joseph's Health, Syracuse , RN Health Coach, Healthcare , Syracuse, New York
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