Jennifer Robinson

Develops an ongoing relationship with patients who have chronic complex diseases by acting as a liaison between the patient and their healthcare team. The Health Coach is active in patient education, goal setting, and self-management support for these patients.

Job Functions:

• Acts as the primary contact person for the patients/families with chronic disease care to ensure and promote continuity of care. Contacts patients prior to and/or after physician visits, monitors patient compliance with the treatment plan and appointments and assists with reminder calls if appropriate.
• Provides ongoing communication with physicians and staff regarding patients appropriate for chronic disease care and works closely with physicians, staff and patients in coordinating chronic disease care. Coordinates necessary patient education material.
• Collaborates with physicians and staff in patient care visits using evidence based medicine guidelines for chronic disease care. Assists physicians utilizing Healthy Planet, running reports, and interpreting results.
• Facilitates data collection and analysis of chronic disease measures and identifies opportunities for improvement. Assists in the development of data collection tools and collection of data related to these tools for chronic disease care.
• Manages and monitors the database registries for chronic disease care and prevention wellness.
• Assists physicians and staff with clinical information regarding patients/families with chronic disease care. Participates in the facilitation of continuous access to the medical record and plan of care.
• Participates in patient safety, Joint Commission, and audits for primary care clinics. Acts as a resource for compliance reporting and accreditation requirements according to established guidelines and within established time frames.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Provides direct nursing care in accordance with established policies, procedures and protocols of the organization. The nurse maintains the knowledge and skills necessary to provide care appropriate to the age of the patients served on the assigned unit. The nurse facilitates the coordination of patient care within the interdisciplinary care team and provides patient education to assure safe patient discharge.

Job Functions:

• Performs daily rounds on all patients assuring quality customer service by coordinating and taking action on any requirements not met.
• Develops a plan of care based on assessment that reflects the patient's physical, psychological, social, educational, developmental and rehabilitative needs based on patient's age, ethnic origin, economic status, lifestyle, creed or philosophical beliefs.
• Assesses the patient's condition and nursing needs, sets goals, and prescribes appropriate nursing actions to meet those goals and the physical, psychological, social, and rehabilitative needs of the patient, including discharge planning.
• Assesses, intervenes, and reassesses the patient's self-report/symptoms of pain promptly and takes appropriate action according to standard operating procedure.
• Identifies the early warning signs of a change in a patient's condition and responds appropriately to a deteriorating patient, including contacting responsible clinicians as indicated by standard operating procedure. Assists with or institutes emergency measures for sudden adverse developments in patient conditions.
• Reports pertinent observations and reactions regarding patients to the appropriate multidisciplinary team member and records those observations accurately and concisely. Ensures that intervention or referrals are made promptly. Completes and submits all incident reports (patient, visitor, staff) prior to the completion of each shift.
• Establishes and maintains communication and utilizes educational opportunities with patients and other significant individuals.
• As early as possible, begins discharge planning, appropriate education and counseling based on identified needs to optimize patient/family understanding. Evaluates and documents according to standard operating procedure.
• Assigns or delegates, within the scope of practice, education and experience, the responsibility for performance of nursing interventions to other persons for which that person has the necessary skills and competence to accomplish safely.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Provides direct nursing care in accordance with established policies, procedures and protocols of the organization. The nurse maintains the knowledge and skills necessary to provide care appropriate to the age of the patients served on the assigned unit. The nurse facilitates the coordination of patient care within the interdisciplinary care team and provides patient education to assure safe patient discharge.

Job Functions:

• Performs daily rounds on all patients assuring quality customer service by coordinating and taking action on any requirements not met.
• Develops a plan of care based on assessment that reflects the patient's physical, psychological, social, educational, developmental and rehabilitative needs based on patient's age, ethnic origin, economic status, lifestyle, creed or philosophical beliefs.
• Assesses the patient's condition and nursing needs, sets goals, and prescribes appropriate nursing actions to meet those goals and the physical, psychological, social, and rehabilitative needs of the patient, including discharge planning.
• Assesses, intervenes, and reassesses the patient's self-report/symptoms of pain promptly and takes appropriate action according to standard operating procedure.
• Identifies the early warning signs of a change in a patient's condition and responds appropriately to a deteriorating patient, including contacting responsible clinicians as indicated by standard operating procedure. Assists with or institutes emergency measures for sudden adverse developments in patient conditions.
• Reports pertinent observations and reactions regarding patients to the appropriate multidisciplinary team member and records those observations accurately and concisely. Ensures that intervention or referrals are made promptly. Completes and submits all incident reports (patient, visitor, staff) prior to the completion of each shift.
• Establishes and maintains communication and utilizes educational opportunities with patients and other significant individuals.
• As early as possible, begins discharge planning, appropriate education and counseling based on identified needs to optimize patient/family understanding. Evaluates and documents according to standard operating procedure.
• Assigns or delegates, within the scope of practice, education and experience, the responsibility for performance of nursing interventions to other persons for which that person has the necessary skills and competence to accomplish safely.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Provides direct nursing care in accordance with established policies, procedures and protocols of the organization. The nurse maintains the knowledge and skills necessary to provide care appropriate to the age of the patients served on the assigned unit. The nurse facilitates the coordination of patient care within the interdisciplinary care team and provides patient education to assure safe patient discharge.

Job Functions:

• Performs daily rounds on all patients assuring quality customer service by coordinating and taking action on any requirements not met.
• Develops a plan of care based on assessment that reflects the patient's physical, psychological, social, educational, developmental and rehabilitative needs based on patient's age, ethnic origin, economic status, lifestyle, creed or philosophical beliefs.
• Assesses the patient's condition and nursing needs, sets goals, and prescribes appropriate nursing actions to meet those goals and the physical, psychological, social, and rehabilitative needs of the patient, including discharge planning.
• Assesses, intervenes, and reassesses the patient's self-report/symptoms of pain promptly and takes appropriate action according to standard operating procedure.
• Identifies the early warning signs of a change in a patient's condition and responds appropriately to a deteriorating patient, including contacting responsible clinicians as indicated by standard operating procedure. Assists with or institutes emergency measures for sudden adverse developments in patient conditions.
• Reports pertinent observations and reactions regarding patients to the appropriate multidisciplinary team member and records those observations accurately and concisely. Ensures that intervention or referrals are made promptly. Completes and submits all incident reports (patient, visitor, staff) prior to the completion of each shift.
• Establishes and maintains communication and utilizes educational opportunities with patients and other significant individuals.
• As early as possible, begins discharge planning, appropriate education and counseling based on identified needs to optimize patient/family understanding. Evaluates and documents according to standard operating procedure.
• Assigns or delegates, within the scope of practice, education and experience, the responsibility for performance of nursing interventions to other persons for which that person has the necessary skills and competence to accomplish safely.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Ensures health history is completed; assesses and coordinates admissions of patients; individualizes patient care guidelines; ensures that intervention or referrals are made promptly; identifies discharge planning/education needs; provides patient/patient’s family with appropriate education; reviews patient care guidelines/patient care plan; completes all documentation and monitors pre-admission program. Patients cared for include infants, children, adolescents, adults and geriatric.

Job Functions:

• Ensures health history is completed using information form patient/patient’s family and previous medical records, according to standard operating procedure.
• Assesses and coordinates admissions of patients from nursing homes or group homes, working with residence staff and Social Services as appropriate.
• Individualizes patient care guidelines and assesses for any needs of intervention or referral.
• Ensures that intervention or referrals are made promptly, particularly when exceptions occur concerning special needs or unusual findings of the patient.
• Identifies discharge planning/education needs as early as possible, documents and plans in order to meet patient needs..
• Provides patient/patient’s family with appropriate education based on identified needs to optimize patient/patient family understanding, i.e., Advance Directives, etc.
• Reviews patient care guidelines/patient care plan with patient and patient’s family as needed to help patient achieve their expected outcomes.
• Completes all documentation according to standard operating procedure.
• Demonstrates the ability to adjust own schedule to meet fluctuation in patient workload.
• Monitors pre-admission program effectiveness by evaluating, initiating and participating in restructuring of current and new programs.
• Performs pain assessment and takes appropriate action according to standard operating procedure.

Performs and documents assessments appropriate to licensure, ensures health history and admission process is completed and that intervention or referrals are made. Identifies discharge planning and education needs, provides patient care, and performs personal cares. Communicates patient progress, and adjusts own workload.

Job Functions:

• Assists the registered nurse or other licensed practitioner in the identification of patient needs, priorities of care and goals based on patient's age, ethnic origin, economic status, lifestyle, creed or philosophical beliefs. Contributes to the evaluation of the plan of care by gathering, observing, recording, and communicating patient responses to nursing interventions. Modifies the plan of care in collaboration with licensed practitioner.
• Demonstrates competency and ability to carry out department specific functions in accordance to the department's standards of care, policies and procedures. Performs other duties as assigned to meet the needs of the department/organization.
• Functions as a member of the multidisciplinary team, contributing to the implementation of an integrated patient-centered care plan.
• Assigns or delegates the responsibility for performance of nursing interventions to other persons for which that person has the necessary skills and competence to accomplish safely.
• Identifies the early warning signs of a change in a patient's condition and reports appropriately. Implements nursing interventions and prescribed medical regimens in a timely and safe manner and documents nursing care provided accurately and timely.
• Collaborates and communicates relevant and timely patient information with patients/families and other multidisciplinary team members to ensure quality and continuity of care.
• Reports the patient's self-report/symptoms of pain promptly according to standard operating procedure.
• Participates in the health education approved by a licensed practitioner.
• Assists in the discharge planning, appropriate education and counseling based on identified needs to optimize patient/family understanding.
• Performs other duties as assigned or needed to meet the needs of the department/organization.