Chronic Care Coordinator - North Country Hospital

Who we Are:

Nestled into the most northern part of Vermont, North Country Hospital is a community-focused 25 bed critical access hospital, where we prioritize the well-being of our neighbors. North Country Hospital is more than just a healthcare provider; we are a vital part of the community, working together to build a healthier future. Our patient’s health is our priority, and we go above and beyond to care in every way possible.

Position Statement

The Chronic Care Coordinator will be responsible for coordinating the care of patients with or at risk of chronic conditions. This position will also provide direct services to patients and/or families in understanding and adapting to the realities imposed by illness, as well as intervention and plan of care to meet social/health needs in coordination with providers and multidisciplinary team utilizing available community resources.

Key Responsibilities:

Chronic Care Coordinator I:

• Provides direct services to patients and/or families; conducts and documents interviews with patients and intervention (care plan) efforts; conducts psychosocial and clinical-related assessments to identify gaps; utilizes/refers to community resources as necessary; offers emotional support in relation to health/social needs and plan of care at home; assists with end-of-life care planning, advanced directives, or other services, and arranges for nursing facility and rehab center care, etc.
• Coordinates transition of chronic care for patients between hospital, nursing home and outpatient setting.
• Identifies barriers and finds solutions to resolve the barriers.
• Provides educational resources specific to the patient’s health needs, utilizing written materials, video materials, group information, and/or web-based education modules. May assist in glucometer or other teaching if trained and signed off by clinical staff.
• Works with the practice managers and providers to champion quality-improvement initiations in the practices by using clinical information to identify clinical areas for improvement.

Chronic Care Coordinator II:

Includes all responsibilities of Chronic Care Coordinator I plus the following:

• Provides short-term case management for patients with complex medical needs.
• Reviews medications and follow-up care with patient in coordination with the primary care team. Provides medication-specific teaching as needed.
• Provides targeted clinical education for a variety of chronic diseases.

Knowledge, Skills and Abilities:

• Previous experience working in a primary care office.
• Previous experience working with local and state social services and health care agencies.
• Experience working with care management teams is a plus.

CCC I: Background in primary care clinic or hospital system as MA, LNA, health coach, medical technician, or similar.

CCC II: Maintains current Vermont RN license and/or LICSW. Certification as a case manager is encouraged within two years of hire.