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Nurse Patient Care Leadership (Nurse Team Manager) Staff Support
Huddle: Planned Care Complex Care Management Nurse Visits Co-Visits w/Provider Health Education Triage Administer Medication Staff Support Manage and support pod flow Assist MAs as needed Assist provider w/complex pts Phone Follow-up Tasks from Provider Leadership (Nurse Team Manager) Pod outcomes Create and oversee QI Supervise MA Team Managers Strategic vision
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Medical Assistant Lab Patient Care Equipment and Tests Administrative
Huddle: Planned Care Vitals, HPI MA Standing Orders Immunizations and Injections Exam Room/Procedure Setup Lab Urine culture Hcg Blood Draws A1c Strep Equipment and Tests EKG Audiometer Vision Test Autoclave PulseOx NST Ultrasound Administrative Schedule Diagnostic Testing & Imaging Prior Authorization Administer Risk Assessments Tasks from Provider Patient Program Paperwork Manage Rx Refills
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Case Manager Care Coordination Health Education Health Coach Screening
Basic Nutrition, Anticipatory Guidance, Chronic Disease, New Born, OB, Tobacco, Stress Mngt Group Visit Facilitation Care Coordination Organizing Patient Care Activities Support Complex Care Community Resources Outreach TOC Home Visits Health Coach Chronic Disease Self Management Low Level Behavioral Health Interventions Screening Administer Health Risk Assessments
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Manage Community Resources
Specialty Referral Case Manager Care Coordination Arrange Specialty Care Appointments Prior Authorization Documentation to Specialty Provider Follow-Up on Open Referrals Document Consult Reports Manage Community Resources Determine Patient Payment Programs w/Specialists Maintain Specialty Provider Database
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Schedule & Administrative
Front Desk Patient Check-in Copay Collection Insurance/Discount Verification New Patient & Risk Assessment Paperwork Outreach Chronic Disease Outreach Registry No Show Outreach Provider Follow-up Tasks (phone/mail) Schedule & Administrative Manage Provider Schedule Schedule Future Appointments Patient Mailings Patient Portal Enrollment and Management Patient Registration
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Clinical Pharmacist Patient Care Population Health
Internal consults by PCPs for: Uncontrolled diabetics Anticoagulation Complex medication interaction review Subject matter experts for some group visits Population Health Manage fluid individual panels of uncontrolled diabetics in consultation with PCP
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Referral Coordination
Hygienist Patient Care Anticipatory guidance for well children regarding oral health Flouride varnish for applicable pediatric patients Carries risk assessments Subject matter experts for well child cluster visits on the care team in the summer and Centering Pregnancy and Centering Parenting group visits Referral Coordination Help care team patients navigate into our dental clinics for more extensive dental care services as available based on our populations of focus
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Referral Coordination with specialist mental health care
Behavioral Health Professional Patient Care Solution-focused brief interventions for co-morbid behavioral health diagnoses (i.e. depression, anxiety, PTSD, substance abuse) Referral Coordination with specialist mental health care
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Registered Dietician Patient Care Referral Coordination
Supporting clinical consult for diagnoses: Gestational diabetes, type 1 and type 2 diabetes, obesity, gout, hypertension, hyperlipidemia, prediabetes, metabolic syndrome Group visits: Choose to Live Healthy, Clinica Moves Referral Coordination WIC, farmers market voucher program, community-based wellness programs
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PCP (MD, DO, NP, PA) Patient Care Physical exam assessment
Minor office procedures Chronic disease management plans Medication monitoring De facto leaders on the care team Advocates for population health Inpatient family medicine care (internal medicine, pediatrics, obstetrics)
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Patient Care Labs Equipment/Tests Administrative
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The Provider Physician Nurse Practitioner or Physician Assistant
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Nurse Staff Support/Leadership Patient Care
Panel Management/Quality/Population Health Staff Support/Leadership Patient Care
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