JOB SUMMARY: The Pediatric Complex Care Manager delivers clinical patient visits and manages complex care. This position is clinically and administratively responsible to the Pediatrics Department and reports to the Site Medical Director at East Cliff Family Health Center. This individual delivers care to patients utilizing the clinical process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with patients, families, and health team members while maintaining standards of professional nursing, utilizing all established procedures, policies, and standards. In addition, this position conducts care management for patients with complex medical and/or psychosocial needs. The position is designed for a Nurse Practitioner or Physicians Assistant.
The overall goals of the Santa Cruz Community Health Centers Pediatrics Services are:
- Provide excellent healthcare for low-income children.
- Provide excellent healthcare for medically complex children.
- Operate as a community based Pediatric Patient Centered Medical Home.
- Practice pediatric primary care to improve health for the entire community.
- Support excellence in pediatric clinical activities for Family Medicine.
- Integrate Medical and Behavioral Health services to the greatest extent possible for evaluation, treatment, and prevention of disease by identifying and intervening on the social determinants of health.
- Develop and maintain strong active involvement with our community partners for child and family health and wellness.
Within our Pediatrics Service at SCCHC we care for children with medical and/or psychosocial complexity (CMC). The main focus is on children of Clinical Risk Group 5 (CRG5), which is a lifelong chronic condition involving one or more body system.
This role supports SCCHC’s objectives around the care of CMC:
Objective #1: Establish a patient registry of CMC patients, based on set criteria.
Objective #2: Perform assessment of social determinants of health in all patients engaged in care management, using a standardized tool, and both address and link to resources pertaining to social determinants in 50% of CMC patients.
Objective #3: Create, maintain and employ a multi-disciplinary Care Plan for incorporating medical complexity, psycho-social stressors, social determinants of health, and family wishes and values for all patients engaged in care management that includes input from patient, family, primary care provider, behavioral health provider, specialist, and others as necessary.
Objective #4: Develop method to monitor utilization of medical care outside of medical home, such as pediatric subspecialists, emergency department use and hospitalization.
- Create a registry for CMC patients based on set criteria as determined by the Pediatric Care Team and best practices.
- Engage at least 50% of patients included in the registry in a Care Management Plan for appropriate treatment and navigation to outside resources. Compile and maintain Care Management Plans using interviews with patients and families, medical documents from specialists, school records and ongoing clinical care.
- Perform an assessment of social determinants of health, using a standardized tool, for all patients in care management.
- Compile Care Plans for CMC patients using clinical notes, other available clinical information and family interview. This duty requires translating plans from medical providers, emergency department, hospital and family, which entails interaction with medical chart and directly with medical providers.
Family Centered Care:
- Incorporate patients and their families into individual care and into the design, implementation and evaluation of health systems and programs and policies for our clinical services.
- Communicate with families of CMC patients, monitoring their needs, barriers to care, satisfaction and expectations. These are conducted through in-person scheduled visits, phone advice and phone triage.
- Coordinate community and family support resources for CMC patients.
- Serve on the Quality Improvement Committee to improve systems of care for Pediatric Care Team with emphasis on CMC patients.
- Support family advisors for Quality Improvement.
Coordinated Clinical Care:
- Deliver excellent healthcare to pediatric patients, both CMC patients and general pediatrics.
- Working primarily with the Pediatric Care Team (Pediatric Providers and Medical Assistants) on real time clinical care coordination. As needed, working with the Clinic Care Teams (all Medical Providers, Medical Assistants, Behavioral Health Providers, Case Managers, other RNs in our agency, the front office staff and the call center staff) on real time clinical care.
- Working with our Behavioral Health Team to incorporate psycho-social needs assessment, treatment and case management.
- Communicate with medical specialists, case managers, hospitalists and emergency department staff from our medical neighborhood and tertiary care centers.
- Guide scheduling of CMC patients with medical assistants, front office staff and call center staff.
- Conduct appropriate patient education with Pediatric Care Team.