Primary Functions:
1. In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up.
2. Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
3. Complete a comprehensive assessment of biopsychosocial, cultural and language support and self-management support needs.
4. Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, screenings and tests for care managed patients.
5. Assist patients in problem-solving potential issues related to the health care system, financial and psychological barriers.
6. Be the system navigator and provide direct point of contact access for patient and family questions and concerns.
7. Ensure open communication regarding patient interactions with physicians and office staff.
8. Arrange referrals, screenings and test procedures.
Secondary Functions:
1. Prepares and distributes documents/materials for furthering education of medical home program.
2. Works together with other staff members on projects, determining scope, timeline for implementation and outcomes.
3. Works as a team member with emphasis on ensuring internal/external customer needs are met.
4. Participate in supporting quality improvement implementation of new forms, processes and procedures
Lancaster General Health (LG Health) is a 623-licensed bed not-for-profit health system with a comprehensive network of care encompassing Lancaster General Hospital (LGH) and Women & Babies Hospital, including a Level III-B Neonatal Intensive Care Unit. Outpatient services are provided at the Downtown and Suburban Outpatient Pavilions, along with additional Outpatient Centers and Express and Urgent Care locations throughout the region. Lancaster General College of Nursing & Health Sciences is a private, co-educational, Middle States-accredited four-year college offering a variety of associate and baccalaureate degree and certification programs in healthcare.
Other system organizations include: VNA Community Care Services; Lancaster Rehabilitation Hospital, in partnership with Centerre-Healthcare; and Lancaster General Medical Group, comprised of more than 100 family doctors and specialists and more than 20 offices throughout the area.
Designated a Magnet hospital for nursing excellence, LGH has been recognized regionally and nationally for its cardiology, intensive care unit and orthopedic services. Other key specialty services include open-heart surgery, obstetrics neurosurgery, trauma, pediatric care and inpatient and outpatient Behavioral Health. Outpatient programs and services include a Diabetes and Nutrition Center, Sleep Medicine Center, Wellness Center, Wound Care & Hyperbaric, Interventional Radiology, and Occupational Medicine. As a member of the Penn Cancer Network, LG Health has access to the vast research and technological resources of one of the nation’s foremost cancer institutes.
Lancaster, PA 175604
