Nurse Care Coordinator

Job summary/Objectives

The MAT Nurse Care Coordinator is responsible for coordinating and providing clinical care of patients receiving Medication Assisted Therapy (MAT) for opioid dependance and is located in the offices of physicians prescribing Buprenorphine.

Essential functions

• Provide high-quality health care services informed by evidence-based clinical practice guidelines and within the scope of practice per license. Follow standards of practice as outlined by, but not limited to
• Vermont State Board of Nursing for Registered Nurses and Licensed Practical Nurses
• Coordinate and facilitate access to appropriate services for individuals with Substance Use Disorders, including but not limited to
• Preventative and health promotion services
• Mental health, psychiatric and substance use screening and connection to services
• Comprehensive care coordination and transitional care across settings (including appropriate follow up from inpatient to other settings such as participation in discharge planning and facilitating transfer to and from different levels of care or specialties)
• Chronic disease management, including self-management support to individuals and their families
• Individual and family support, including referral to community, social support and recovery services
• Collaborate care with other involved or referring providers or agencies
• Monitor, respond to and track calls to the MAT line
• Screen for alcohol use and provide education and recommendations for medication to support recovery efforts
• Provide comprehensive care coordination to patients being prescribed medications for Opioid Use Disorder (MOUD) by an LHP Provider
• Engage in co-visits with prescribing providers and patients
• Develop and maintain shared person-centered care plan that supports ongoing MOUD services and integrates clinical and non-clinical health goals
• Support, when appropriate, measures to taper/wean patients off MOUD
• Coordinate care with pharmacies to ensure that patients maintain medication access and reduce barriers to medication access
• Monitor and coordinate need for bloodwork associated with MOUD
• Provide education and screening for medical issues or communicable diseases that are a higher risk for patient population
• Participate in maintaining system of care for Rapid Access to MOUD (RAM)
• Communicate available block times within LHP to community partners
• Coordinate appointments, screening and plan for ongoing MOUD care to support buprenorphine induction
• Schedule, preform and monitor unscheduled, random pill counts and urine screening
• Coordinate laboratory specimen obtainment
• Blood draws
• Oral swabs
• Collection or monitoring of collection of urine samples for urine drug screening
• Provide home visits as needed
• Provide education, support in accessing, administration and training for administrating long-acting injectable buprenorphine
• Uphold best practices and internal protocol for storage of medications
• Coordinate with appropriate clinical service partner including, but not limited to
• Work closely with other MAT/CHT staff to provide improved outcomes for the patients referred to the MAT program within and outside of the Morrisville HSA
• MAT Clinician or other involved Substance Use clinician
• Psychiatric providers
• Hub services
• Court Diversion
• DCF
• Probation and Parole
• Recovery support
• Demonstrate a capacity to use health information technology to link services, facilitate communication among team members, communicate with patients and provide feedback to practices, as feasible and appropriate
• Assist in tracking and reporting on patient population required by the State Plan Amendment
• Assist with access the VPMS (VT Prescription Monitoring System) controlled medication history reports for patients
• Complete work accurately and in timely manner including documentation within the electronic medical record (EMR) and data tracking as related to duties
• Participate in required departmental activities
• Attend mandatory staff meetings and committee meetings as deemed appropriate by CHT and MAT Team Manager
• Complete work accurately and in a timely manner including documentation within the electronic medical record (EMR) and data tracking as relates to duties,
• Demonstrates collegiality and commitment relevant to the mission of Lamoille Health Partners and CHT.
• Maintain absolute confidentiality of all patients records, medical treatments and diagnoses and abide by all LHP policies and procedures.
• Serve as a resource and provide education as needed to staff regarding the special needs of the underserved and resources available to meet those needs.
• Participate in quality initiatives as designated by the CHT & MAT Team Manager in collaboration with Director of Quality & Risk Management.
• Participate in Patient Centered Medical Home (PCMH) accreditation process
• Work closely with all staff members to perform rapid-cycle testing of initiatives in the form of Plan-Do-Study-Act (PDSA) model and other quality projects
• Service as a Superuser as needed

Education/Experience

• Licensure: Current, active, and unencumbered Registered Nurse (RN) license in the State of Vermont (or applicable multi-state license).
• Two or more years of experience meeting chronic care needs of patients, preferably in a primary care setting
• Excellent interpersonal skills with a strong understanding of patient centered engagement
• Ability to maintain a high level of confidentiality
• Strong computer and organizational skills as well as the ability to multi-task, respond to shifting priorities and able to work under pressure while meeting all required deadlines.