Chronic Care Lead Nurse at Avenue Healthcare

Job Objective/Purpose

The Chronic Care Lead Nurse performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care nurse works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision- making.

Key Responsibilities

• Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner.
• Responsible for registry of chronic care management (CCM) to patients.
• Validates enrollment of CCM patients based on provider request
• Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR.
• Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.
• Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.
• Facilitates patient access to appropriate medical and specialty providers.
• Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates
• Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education
• Educates patient and family/caregiver(s) about relevant community resources.
• Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.
• Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
• Supports patient self-management of disease and behavior modification interventions.
• Provides patient health counseling, education and instruction.
• Any other duty assigned by your immediate supervisor in line with the job description.

Person Specification

• Graduate of an accredited nursing school as a Registered Nurse with a valid license with the Nursing Council of Kenya.
• Updated BLS, ACLS/ATLS certificate
• Minimum of 3-6 years work experience in a healthcare setting involving patients with complex chronic disease states preferred.
• Customer focus, empathetic and emotional intelligence
• Strong interpersonal and communication skills
• Organizational awareness and attention to detail
• Team work and result oriented
• Ethical and reliable