Accountable Care Manager-CHRONIC DISEASE COOR.

NYC Health + Hospitals Is currently seeking several Chronic Disease Nurses who will have dual reporting

structure. The RN Chronic Disease Coordinator will report to Facility ambulatory CNO. Duties will include:

• Work at one of our adult primary care clinics to Improve the quality of chronic disease care.

• Focus 50% on direct patient care and 50% on performance Improvement responsibilities.

• Provide direct cllnical care, for patients with uncontrolled chronic conditions e.g., hypertension or diabetes.

This can Include:

• Educate patients about diagnosis, treatment, medications, and needed follow-up

• Conduct nurse follow-up visits for HTN management, insulin teaching and/or titration.

• Identify underlying challenges such as socioeconomic, cultural, physical or language barriers

• Collaborate with patients, families and care team to address barriers, using strategies such as motivational lntervlewlng and brief action planning.

• Liaise with social work department to develop strategies to address social determinants (e.g.,homelessness or food Insecurity)

• Organize group medical visits and moderate discussion to optimize peer-peer support

• Collaborate with central office staff in the Office of Population Health to implement chronic disease performance Improvement Initiatives.

• Report progress bl-weekly on facility chronic disease initiatives

• Coordinate and collaborate with facility clinical, nursing and administrative leadership to drive continuous performance improvement for chronic disease management

• Educate ambulatory nursing staff on chronic disease initiatives

• Monitor adherence of ambulatory nursing staff to performance improvement plans

• Track and share quality metrics with stakeholders across the facility

• Implement OPH disease management toolkits to drive facility change.

• Coordinate with OPH and faclllty leadership to address barriers in achieving Improvement goals.