GUIDE Care Navigator
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Posted Job Title
GUIDE Care Navigator
Job Profile Title
Coordinator B
Job Description Summary
The Penn Memory Center at the University of Pennsylvania seeks to hire a Care Navigator to join their multidisciplinary team to support the Guiding an Improved Dementia Experience (GUIDE) program. The GUIDE program provides comprehensive, coordinated dementia care and aims to improve quality of life for people with dementia, reduce strain on their caregivers/support network(s), and enable people with dementia to remain in their homes and communities. This full-time position in an outpatient practice in the Perelman Center for Advanced Medicine will be responsible for supporting older adults with Alzheimer's disease and other dementias, and their caregivers/support network(s). The Care Navigator will serve as a primary point of contact for patients with dementia and their caregivers, providing continuous, proactive, and personalized support. The Care Navigator collaborates with physicians, nurses, social workers, and other members of the care team to provide support, education, and care coordination to patients with dementia and their caregivers. The Care Navigator is the primary point of contact for patients and their caregivers enrolled in the program. The Care Navigator will participate in training on common issues affecting patients with dementia and their caregivers. They will maintain regular contact with program participants. They will review clinical cases weekly with other care team members. They will assist with collecting data on patient quality of life, caregiver distress, and health-related social needs. They will report to a social worker or nurse manager and will also provide feedback directly to clinicians and other care team members.
Job Description
Job Responsibilities
1. Primary Contact and Support:
o Act as the primary point of contact for patients with dementia and their caregivers to gauge completion of specific health interventions outlined in the Care Plan; such as, completion of appointments, medication compliance, use of community resources and other recommended follow-up activities.
◦ Provide education about dementia, its progression, and what to expect.
◦ Offer emotional support and active listening to caregivers.
◦ Under clinical supervision, ask screening questions and document patient safety, behavior, function, medications, care needs, and advanced care plans
◦ Under clinical supervision, ask screening questions and document caregiver issues such as burden, depression, and poor coping
1. Care Coordination:
◦ Screen for unmet care needs, including clinical or medication issues, behavioral issues, safety risks, and psychosocial well-being.
◦ Provide connections to local community services and resources.
◦ Assist with medication reconciliation and medication management strategies, including monitoring for side effects and changes in function or behavior.
◦ Monitor delivery of care through documentation and tracking of interventions in the electronic health record (specialty visit follow-up, labs, diagnostic studies, etc.).
2. Person-Centered Planning:
◦ Assist with developing and maintaining personalized care plans that incorporate the beneficiary's goals, strengths, preferences, and needs.
◦ Help guide each dyad through the process of advance care planning.
◦ Modify care plans as needed to reflect changes in circumstances, goals, and preferences.
◦ Ensure care plans are incorporated into the beneficiary's electronic health record and shared with their primary care provider and other relevant healthcare providers.
3. Education and Training:
◦ Educate caregivers on managing dementia-related behaviors, maintaining safety in the home, and other caregiving tasks.
◦ Provide resources to help caregivers maintain their well-being and manage stress.
◦ Participate in Care Navigator training for their own professional development (initial and ongoing)
4. Ongoing Monitoring and Support:
◦ Maintain regular contact with beneficiaries and their caregivers, adjusting the frequency of contact based on the patient's complexity and needs
◦ Use various modalities (in-person, phone, video calls) for ongoing contact.
◦ Ensure 24/7 access to support for beneficiaries and caregivers during business hours.
5. Collaboration with Clinical Team:
◦ Consult with and escalate complex or medical issues to licensed clinical team members, such as clinicians, nurses, social workers, or pharmacists.
◦ Report screening to the clinical team who will provide direction in implementing a care plan with the Care Navigator, patient, caregiver, health care and community service providers.
◦ Participate in interdisciplinary team meetings to coordinate care and address any emerging issues.
Qualifications
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