Visit Facilitator (Wooster)

WELLBE INTRODUCTION

The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care – from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care. WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

GENERAL SUMMARY

The LPN Visit Facilitator is responsible for modeling the WellBe values and mission and will play a vital role in delivering white glove, high-quality services to patients who need your help in the comfort of their own home. This position requires a combination of conducting in-person patient visits, supporting administrative tasks, and facilitating telehealth patient consults with Nurse Practitioners or Physicians as required. The LPN Visit Facilitator role will be the local market expert and will act as a connector for patient support services across the WellBe platform. This role will be responsible for working closely with our Telehealth provider team and social worker team to provide deliver the highest quality of care to our patients. The role has no direct reporting responsibility but will function as part of an integrated, interdisciplinary patient care team. LPN staff in these roles will help foster positive and effective working relations with senior leadership and management, local market management and business ancillary departments for the purpose of achieving the company’s vision, mission and objectives. S/he is responsible for following the rules and regulations of state and federal regulatory agencies and other certified agencies for their region.   Daily, local travel to meet patients and the community will be an essential part of your role.

SKILLS & COMPETENCIES

• Facilitate in-home Telehealth visits between WellBe APP-Nurse Practitioner and Patient, including initial patient assessments and on-going follow-up visits as appropriate per patient need.
• Complete and document thorough home safety inspection during patient visits.
• Check and record health vitals including weight, blood pressure, heart rate, lung sounds, and blood sugar levels, as well as potential health challenges noted during the home visit and/or reported by each patient.
• Provides support for patient care needs at the direction of the assigned Provider.
• Responsible for patient education needs at the direction of the assigned Provider.
• Reviews patient care interventions and assessment of patient needs for transitions of care, end of life discussions, addressing HEDIS gaps (med adherence) and palliative care interventions.
• Completes and submits all documentation/paperwork requirements daily.
• Attends Interdisciplinary Team (IDT) meetings and provides additional information on any patient/family interactions.
• Collaboration with other care team members on patient care strategies.
• Attend all required trainings, including equipment/device training. Ongoing training to be expected and additional education, skills, and protocols will be added.
• Maintain all required certifications as an active Oregon State Registered Nurse and supply valid copies of all certifications and driver’s license prior to their expiration dates as well as submit a copy of driver’s license for the yearly MVR pull.
• Other tasks needed to accomplish team’s objectives/goals.
• Build relationships with local community providers and care givers to maintain WellBe presence and reputation in local markets.
• Operate and drive the company vehicle in a safe and professional manner while always exercising due regard for self and other motorists.

QUALIFICATIONS

 Educational/License Requirements:  

• Active Oregon State Licensure and reside in the state of Oregon.
• 3+ years as an LPN in a direct, patient-facing care delivery role
• Prior Telehealth experience preferred.
• Previous experience in home care, hospice, palliative care, or geriatrics strongly preferred, other complex patient health care experience also beneficial.
• Possess a valid driver’s license with an acceptable driving record.
• Requires proof of active auto insurance policy.
• CPR Certification required.

Required Skills and Abilities:

• Strong communication skills, with the ability to effectively interact with patients, families, and remote healthcare professionals.
• Ability to work independently and make sound decisions while adhering to established protocols and guidelines.
• Excellent organizational and time management skills to handle administrative tasks and facilitate telehealth consultations.
• Understanding of Risk Assessment and Quality measures
• Familiarity with electronic medical records (EMR) systems and basic computer skills
• Understanding of full-risk or value-based care
• Experience working with culturally diverse and underserved populations.

Supervisory Responsibility: No supervisory responsibilities.

Travel requirements: Travel may be required up to 100% locally or nationally.

Physical Demands: The physical demands described here are representative of those that must be met by a colleague to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the colleague is regularly required to use hands to finger, handle, or feel; talk and hear. The colleague frequently is required to stand, sit, and reach with hands and arms. The colleague is occasionally required to walk; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The colleague must frequently lift and/or move more than 35 pounds. Specific vision abilities required by this job include close vision.

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.