This is a full-time position for an LPN, providing care coordination/management along with implementing prescribed medical treatments, to include patient care and education services. The LPN will work with ill, injured, convalescent, and disabled patients. LPN role will include the provision of care coordination including Medicare Wellness Visits, Chronic Disease Care Management, and Transitional Care Management for high risk patients. Team care member will assist with implementing quality improvement measures to aid in preventing and managing chronic diseases.
ResponsibilitiesCoordinates and provides Medicare Wellness Visits to eligible patients in the primary care practice. Will complete documentation
Coordinate and provides Medicare Wellness Visits to eligible patients in the primary care practice.
Utilize Excel spreadsheets to track patients due for Medicare Wellness VisitsCall and schedule patients dueTrack visits completed using Excel
Work with Medical Assistant and other practice team members. Review patient lists, quality measures, outreach lists and coordinate care for those members who are in need of Medicare Wellness Visits or identified as having quality gaps.
Attend Care Management Meetings, Primary Care Collaborative meetings, and other educational sessions as scheduled. Will complete recommended educational modules as assigned.
Follow chronic disease and preventive care guidelines and ensure that appropriate plans for completion are developed.
Assist patients in developing a personalized wellness plan that includes realistic goals and a plan of action, including advanced care planning.
Provide education and supports patients in learning how to make good choices for themselves that will lead to optimal well-being and a higher quality of life.
Promote patient engagement and compliance with appointments, treatment recommendations and other recommended services.
Complete all tracking and reporting requirements for outcomes and evaluation.
Assist physicians with examinations, minor surgeries, diagnostic procedures and treatments.
Assist in clinic with rooming and triaging patients. 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:
Coumadin Clinic-Check patient’s INR and adjust Coumadin dose as needed. Review and teach diet restrictions. Document results and bill for procedures. Talk to home health nurse re: INR results and adjust doses.Colposcopy Clinic-set up and assist with procedures. Assist physicians with Colposcopy procedures. Process and send specimens to pathology (Sentara or Labcorp). Record in Procedures notebook, follow up for results, physician’s verification and patient notification. Call no show patients and reschedule. Minor surgery clinic-set up clinic and assist with procedures. Process and send specimens. (Dermatology, Labcorp) Follow results for physician verification and patient notification.Flexible Sigmoidoscopy-done during minor surgery. Assist physician. Call patients prior to and after appointment to review prep and answer questions. Treadmill Clinic-prepare patients for testing. Assist with test. Monitor vital signs. Call patient prior to testing, verify appointment, review instructions and answer questions.
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.
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.
LPN Role Post Visit
Provide care plan from visit to include:
Medication listIndvidualized patient goalsReview of chronic diseasesHealth screenings due
Schedule Preventive/screening tests
Including referrals for: TMT, vasectomy, minor surgery, gyn clinic (provide IUDpacket for Mirena, discuss procedure for colpo, CDE referral, Podiatry,
Diabetes Education
Reviewing diabetic flow sheetsTeaching 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:Care preferencesAdvance directivesCaregiver stress supportBereavement supportPerform Functional mood and Cognitive assessmentsCoordinate transitions of care Performs other duties as assigned. QualificationsMust be a licensed LPN in Virginia. One year of LPN experience preferred. Completion of BLS class and re-certification every two years. Ability to make professional nursing decisions up to the scope of practice for licensure and possess the knowledge and critical thinking skills to support those decisions. Posess complex patient assessment and management skills to develop a care plan for Medicare Wellness Visits. Possess basic knowledge of educational behavioral approaches to change behavior. Maintain professional interaction skills with physicians, patients, outside offices, pharmacies, referring agencies, hospital personnel, and support staff.
Location : Location US-VA-Portsmouth