The Nurse Care Coordinator provides clinical care and coordinates services for patients receiving Medication Assisted Therapy for opioid dependence. Responsibilities include developing person-centered care plans, monitoring medication access, performing screenings, and collaborating with multidisciplinary teams.
Requirements summary
Candidates must hold a current, active, and unencumbered Registered Nurse license in the State of Vermont. A minimum of two years of experience in chronic care, preferably in a primary care setting, is required.
professional certificateMulti-taskingConfidentialityPhlebotomyOrganizational skillsInterpersonal skillsPatient educationQuality improvementCrisis managementCare planningChronic disease managementClinical care coordinationElectronic medical record documentationHealth information technologyUrine drug screeningSubstance use disorder screeningMedication assisted therapy
Job description
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.
