Director of Care Integration - Acute Care (Diabetes Patients)
Harris Health System
Location: Houston, Texas
Type: Full Time
Internal Number: 154871
The Director of Care Integration develops strategic direction and implementation of the Harris Health System Diabetes Service Line a collaborative initiative with the Baylor College of Medicine and the University of Texas Health Science Center School of Medicine. Provides administrative oversight by coordinating and providing leadership. Provides evaluation, and improvement of processes directly and indirectly impacting the service line function. Formulates goals/objectives and program targets. Provides innovative leadership to maximize the department's contribution to the overall Harris Health System performance with respect to service line initiatives. Responsible for assuring compliance with all local, state, and federal regulations as well as accrediting organizations as they pertain to specific service line initiatives.
Education/Specialized Training/Licensure: Bachelor Degree in Nursing, Graduate Degree in related healthcare field preferred, and/or Healthcare Professional with extensive clinical experience with diabetes patients.
Work Experience : 3-5 years progressive, outcome oriented management experience in an acute care setting with clinical expertise in the care of the Diabetes patient.
Management Experience : 3-5 years management experience, demonstrates success in planning, program development and operations with emphasis on sound business applications, effective quality/process management and efficient resource utilization. Excellent interpersonal skills to foster an interdisciplinary team approach to services and program delivery. 4. Equipment Operated: Personal Computer
SPECIAL REQUIREMENTS: Communications: Above Average Verbal (Heavy Public Contact) Exceptional Verbal (e.g., Public Speaking) Bilingual Skills Preferred : Languages: Spanish preferred. Writing/Composing (Correspondence/Reports )
Other Skills: Analytical CRT Design Mathematics Medical Terms P.C. Research Statistical Word Proc Work Schedule: Flexible, Travel, On Call Other Requirements: Knowledge of JCAHO, State, Medicare/Medicaid, and other external regulatory agencies.
Typical Duties That May Be Performed 1. Identifies teaching/learning needs within the target population. a. Teaches identified content. b. Evaluates effectiveness of education interventions for individuals and groups within target populations. c. Identifies and evaluates instructional materials, media and formats for appropriateness. d. Participates in the revision of curriculum for identified target population learning needs using evidencebased approach. 2. Uses teaching/learning principles and strategies to guide intervention for patients/families and team members. a. Assesses teaching/learning elements: readiness to learn, level of motivation, attitude toward learning and preferred learning style. b. Determines impact of social, economic and cultural aspects/circumstances. c. Identifies potential barriers to self-management: cognitive and physical limitations, literacy, lack of support systems, negative cultural influences. d. Provides education to staff (as requested) on specific diseases/conditions which aligns with established protocols and guidelines. 3. Uses nursing process, knowledge and skills to educate patients/families and team members. a. Assesses basic chronic disease self-care skills, knowledge, literacy and numeracy. b. Assesses patient/family specific educational needs and level of learning. c. Assesses patient/family motivation and readiness to learn. d. Develops basic plan related to patient acquiring necessary self-care skills based on needs assessment. e. Guides patient/family to set individualized goals or success metrics. f. Documents plan of care ' discharge plan and use of resources to promote continuity of care. g. Evaluates the effectiveness of the teaching/education through follow-up. h. Adapts work and service methods to accommodate the unique physical, psychosocial, cultural, agespecific and other developmental needs of each patient served. 4. Utilizes resources and systems to enhance patient outcomes. a. Implements and individualizes plan of care based on assessment of bio-physical, psychosocial,developmental (age-appropriate), cultural, spiritual and environmental needs of the patient/family to promote independent self-care. b. Identifies resources needed and works through appropriate systems to obtain resources for an individual patient to promote cost-sensitive care. c. Documents use of the nursing process in EMR, including outcomes. d. Uses the EMR and other resources to involve the multidisciplinary team when issues are identified that cannot be resolved at the time of the patient encounter. e. Provides written self-management plan and follow-up as needed. f. Monitors adherence through chart review, readmission data and follow-up contact. g. Submits monthly report by required deadline. 5. Communicates and collaborates with patients/family and team members. a. Establishes and maintains channels of communication to enhance patient throughput and outcomes. b. Collaborates with other healthcare team members regarding patient care issues. c. Uses verbal and written skills effectively to facilitate multidisciplinary collaborative problem solving. d. Reports issues identified to appropriate member of the multidisciplinary team. e. Offers guidance on accessing specialized care and available resources. 6. Maintains professional role and responsibility. a. Adheres to Nurse Practice Act and ANA Code of Ethics to guide practice interventions. b. Assumes responsibility and accountability for own actions to provide safe, competent and ethical care. c. Acts as a resource to new employees and other members of the team to ensure the delivery of quality patient care. d. Participates in programs and activities that foster personal and professional development in specialty area. e. Contributes to data collection and analysis for departmental and system-wide performance improvement activities. f. Maintains professional behavior and completes all mandatory training and developmental activities and meets institutional and departmental health and safety requirements by established deadlines (as indicated in the Nursing Education and Competency matrix). g. Completes 20 hours of continuing education (CEUs) in related field, if no certification is held. h. Completes required hours of continuing education (CEUs) in related field, if certification is held. i. Uses effective communication, conflict management, problem-solving, negotiation, and change management skills. j. Communicates clearly in written and oral presentation. k. Follows chain of command based on location of practice. l. Participates in advocacy activities, including membership in professional nursing and community-based organizations. 7. Patient Satisfaction. Works collaboratively with colleagues to deliver patient/customer services that meet or exceed patient expectations as evidenced by patient satisfaction scores. 8. ServiceFirst. Delivers exceptional customer service by embracing ServiceFIRST standards of behavior during all patient, visitor and staff encounters. Friendliness: Make eye contact and smile. Introduce yourself; offer assistance. Say the patient's name often. Integrity: Ensure our customers' right to privacy and modesty. Do what you say you'll do. Exceed expectations. Responsibility: Live HCHD's mission. Be accountable. Take pride in your appearance and keep our facilities clean. Satisfaction: Say words like, 'my pleasure,' and 'I'll be happy to.' Give everyone prompt service; keep them informed. Teamwork: Respect and encourage co-workers so our guests' needs are met. Encourage co-workers and recognize them for a job well done.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.