Job Information
Spectrum Health Services Disease Management Nurse in Philadelphia, Pennsylvania
Job Descriptions:
Job Summary: The Disease Management Nurse will work collaboratively with patients and Providers across Spectrum sites to provide chronic-disease self-management support to patients between visits. The Disease Management Nurse will provide in-person and virtual chronic disease self-management education, support a panel of patients in remote monitoring programs, develop educational materials, track program metrics, and participate in collaborative projects with community-based organizations and other health centers to improve the health and wellbeing of Spectrum’s patient population.
Essential Functions:
Work with leadership to develop and implement structured disease management programs, starting with self-measured blood pressure. Future programs will focus on diabetes, asthma, and potentially other chronic disease states, such CHF and COPD. Responsibilities include:
Track and respond to patient referrals, meeting patients in-person and virtually to enroll in program. Instruct in use of self-monitoring equipment, medication adherence strategies, and lifestyle strategies for self-management
Manage onsite devices and relationship with DME vendor to provide devices to patients
Receive and review telemonitoring results
Provide patient education regarding their medication regimen, medication adherence strategies, dietary strategies for self-management, physical activity strategies for management and appropriate lifestyle changes such as smoking or alcohol cessation, sleep hygiene or weight management
Work with patients to develop SMART goals around chronic disease self-management, using motivational interviewing techniques and supportive coaching to assist patients in achieving goals
Conduct proactive outreach to patients at scheduled cadence to check in on self-monitoring and medication adherence, goal progress, and assess for any barriers, issues or concerns
Serve as intermediary between patient and provider to troubleshoot barriers, issues and concerns between visits
Flag and review out-of-range readings with provider, work with provider to titrate meds between visits adhering to established nurse-driven protocols, educate patient on regimen changes and ensure new meds obtained
Field incoming calls from enrolled patients
Work with Director of Clinical Informatics and Quality Measures and Director of Care Management and Population Health to track and report program data
Work with Director of Care Management and Population Health to develop templates to document program data in EHR
Participate in meetings related to HCCN-wide initiatives and grants around chronic disease self-management programs
Work with marketing team and Registered Dietician to develop patient-friendly, health literacy-forward print educational materials AND vet pre-made educational resources (stoplight tools, CDC Diabetes Prevention Program (DPP) curriculum, etc.)
Develop Spectrum library of demo devices, including BP cuffs, demo BG monitors, demo insulin pens and administration pads, demo inhalers
Provide one-off education for patients with new chronic disease diagnoses or new medications needed to manage those illnesses (inhalers, insulin syringes or pens, nebulizers, glucometers, CGMs)
Work with clinical nursing team to orient to demo devices, educational materials, meds, self-monitoring equipment so that they can also provide face-to-face education to patients being seen for visits
Work to obtain free, gently used equipment (i.e. refurbished nebulizers, loaner blood pressure monitors) for distribution to patients with insurance barriers to obtaining equipment
Required Experience:
Qualifications/Experience:
BSN degree or higher
At least 3-5 years clinical nursing experience
Strong Microsoft Excel skills
Experience documenting in electronic medical record
Strong knowledge of chronic disease management, including hypertension, diabetes, asthma, CHF, COPD medications and lifestyle management
Motivational interviewing experience
Ability to interact with individuals with diverse cultural, linguistic, and religious backgrounds
Ability to travel between sites as needed
Preferred experience:
Experience in home health, ambulatory care, ambulatory care, care management, or patient education
Knowledge of public benefits and community resources across Philadelphia
Basic understanding of Medicaid and Medicare durable medical equipment (DME) coverage
Familiarity with remote patient monitoring programs
Keyword: Disease Management Nurse
From: Spectrum Health Services, Inc