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Duke Connected Care, a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and itssurrounding areas.

General Description of the Job Class

The Population Health Specialist will develop, implement, and evaluate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy, and training services, in an effort to enable their recovery or management of complex, chronic health conditions.

The Population Health Specialist is responsible and accountable for supporting clinical expertise for specific complex patient populations. This role will perform supporting clinical disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc. The Population Health Specialist functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family, and community.

Patient base consists of patients who are sub-optimal users of healthcare and/or management of chronic disease. Identify any barriers to proper utilization and determine best steps for following treatment recommendations, as well as providing resource/benefit education, counseling, and self-care processes. Focus on improving transitions in care for patients, physicians, family, and community.

The Population Health Specialist will work as an integral part of an interdisciplinary team, ensuring excellence in patient care, to achieve optimal clinical outcomes through a seamless model of access and care.

Duties and Responsibilities of this Level

• Assess patient's condition, locate appropriate treatment and resources, ensure continuity of care and document treatment progression; provide individual counseling sessions concerning rehabilitation treatment and health maintenance.
• Document interventions within medical record system(s) to collaborate with health care providers and monitor treatment programs. Assess the overall health and health education needs of the patient. Review patient data related to disabilities or medical limitations and maintain liaison with primary health care provider.
• Participate in multi-disciplinary teams to promote a healthy context or social environment; developing and supporting local partnerships to broaden the local response to health inequalities and advocate for patient acting in support providers.
• Review and evaluate Admission, Discharge and Transfer (ADT) electronic alerts, electronic medical record notes or other patient trend data. Use communication systems and telephone consultation to ascertain needs of identified patients.
• Conduct community, telephone and practice encounters with patients and other care management team members to identify care plans, barriers, and goals.
• Follow-up with patients and providers on identified health care needs and identify possible resources to address those concerns and/or work with care management team to address concerns in a multi-disciplinary method.
• Facilitate and manage referrals from referral specialist, providers, and other care management staff to ensure that identified red flags and healthcare needs of patients are addressed.
• Provide individual consults to patients on health education issues. Develop the health awareness of individuals, as well as groups and organizations, empowering them to make better health choices.
• Provide specialized treatment, implementation of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures.
• Assess the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Address the total needs of the individual: medical, psychosocial, behavioral, and spiritual.
• Monitor access to care, services, and treatment including linkage to the medical home.
• Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Use proven processes to measure patients understanding and acceptance of the proposed plan(s), willingness to change, and support to maintain health behavior change. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Document and communicate with all providers(s) and member(s) of the care team as needed to minimize fragmented care. This will include navigating transitions of care generally from hospital to home or community facilities.
• Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
• Determine patient care plan using data from multiple sources such as patient medical records, claims, and program metric reports to prioritize individuals for outreach, education, and intervention.
• Participate in quality/performance improvement projects and provide presentations of outcomes in various group settings, including provider and practice meetings, as needed.
• This position may require home visits; however, position specific details and duties are available upon request.
• The work activity and patient acuity levels can create a stressful atmosphere.

Required Qualifications at this Level

Distinguishing Characteristics of this Level

Additional job expectations include the ability to:

• Maintain strict confidentiality

• Promote programs and services to the community

• Build effective and trusting relationships with patients/peers

• Use motivational interviewing and active-listening skills when assessing patient conditions, problems, and interests

• Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions

• Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate

• Use data to analyze trends and to verify data

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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About Duke University Health System

As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.

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