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.
Location: Durham, North Carolina
The Physician Liaison, Post-Acute Care is responsible for designing and executing initiatives to improve health outcomes in Duke Health’s Clinically Integrated Network (CIN), Duke Connected Care (DCC), and the local market.
This Physician Liaison, Post-Acute Care will lead in the administration and development of the Health Optimization Program for Elders Skilled Nursing Facility Collaborative (HOPE SNF Collaborative) and other post-acute initiatives, while also supporting the CIN with network related activities. The HOPE SNF Collaborative is an integral component of the CIN. The Physician Liaison, Post-Acute Care will deliver population management tools to ambulatory, inpatient, and post-acute partners, such as: evidence-based best practice guidelines; quality improvement strategies around change management, systems engineering and rapid-cycles tests of change; care coordination and self-management; and how to use data and analytics to support continuous improvemen
Program Development (40%):
Leads initiatives to optimize relationships and collaboration to improve population health outcomes with primary care practices, collaborative Skilled Nursing Facilities, engaged Home Health Agencies, and other post-acute settings such as assisted living.
Develops and implements specific outreach, relationship building, and collaborative plans to meet goals in collaboration with CIN partners.
Effectively builds relationships with practices and post-acute and transitional care partners (NCHCFA, Alliant Quality, EMS and transportation services, long-term care pharmacies, and therapy services), enhancing care coordination and performance on population health outcomes.
Develop opportunities and processes to improve transitions and promote sustainability (e.g., TeleHOPE, a weekly transitional care videoconference).
Develops processes to connect individuals to timely post-acute services (e.g., 3-day waiver, opportunities to transition patients without engaging ED or rehospitalization).
Works collaboratively with other ACOs (e.g., UNC, Wake Med) to promote shared guidance, outcomes, and tolls in the post-acute arena.
Works collaboratively with other system functions that interact with post-acute providers, primary care practices, such as DUHS case management, the Duke Transfer Center, and Duke MedLink.
Establishes and maintains ongoing engagement and communications with providers, administrators, home health and hospice agencies, other providers (e.g., Monthly HOPE SNF collaborative webinar, WORDS of HOPE e-mail list serve, monthly Home health agency workgroup, Etc.) including routine and follow-up visits and discussions.
Stays abreast of CMS regulatory and payment changes regarding post-acute care to promote better transitions and collaboration across the care continuum and uses consultative approach to engage CIN partners, identify and resolve barriers to performance, and improve population health outcomes.
Connects and advises key inpatient, outpatient and post-acute partners, including providers, practice administrators, referral coordinators, office staff, and others to help achieve better outcomes.
Identifies and executes tactics to promote interaction and engagement including website development, organization and availability of tools, applications, education, site visits, meetings, and other communication methods.
Serve as an active team member: learning from others, valuing all input and expertise, and establishing collaborative relationships
Engagement Planning (20%):
Analyzes quality, cost, and utilization performance to design and implement strategies to build awareness, set goals, and improve performance among SNF collaborative participants, CIN partners, and other post-acute providers.
Develops communication and engagement agendas to promote quality improvement initiatives, workflow redesign, and use of electronic medical record tools to promote high-quality care.
Leverages CRM and PHMO data tools and colleagues to identify factors impeding progress and performance, set goals and enhance outcomes.
Provides market intelligence including routine analysis of the strengths and services of providers participating in the CIN and competitors.
Quality Improvement (40%):
Assists CIN partners with routine review of patient charts, and examines data to gauge and improve performance under payer contracts.
Utilizes knowledge of team dynamics and group facilitation to promote engagement of and SNF team members in QI projects.
Educates team members on quality measures, benchmarks, and reporting requirements.
Provide support to primary care and post-acute providers, administrators, and staff to achieve quality improvement goals and proactively identify opportunities for improvement.
Develop collaborative relationships with PHMO team members, practice leaders, Duke Geriatrics Division members, and Duke Geriatrics Operational Plan Steering Committee to achieve goals.
Provide ongoing training, support and technical assistance to post-acute care providers and participating practices to ensure appropriate quality improvement approaches are being used to optimize results
Utilize and promote the methodologies and tools of continuous quality improvement.
Seek out opportunities to promote staff knowledge and understanding of quality improvement and measurement.
Facilitate development of strategies and best practices to drive improvement.
Ensure timely tracking and cataloging successes/challenges/barriers relating to Quality Improvement initiatives. Catalog PDSA cycles, trainings and resources in order to assist with the ‘spread’ of best practice initiatives.
Ensure timely completion of data collection, documentation and reporting requirements.
Knowledge, Skills and Abilities
Bachelor’s degree in healthcare related field or business combined with relevant and demonstrated experience in quality or process improvement, practice or team facilitation, project management, demonstrated understanding of current trends in healthcare, and proven experience using data to drive improvement
Experience in post-acute care delivery (e.g., skilled nursing facility, home health) and QI for transitions of care across the continuum from hospital to post-acute to clinic and home..
Role requires excellent communication (oral and written), interpersonal and customer service skills, comfort with public speaking, group leadership and facilitation, and demonstrated problem solving and critical thinking skills
Flexibility to adapt to shifting priorities and short-term deadlines
Strong organization and detail orientation skills
Experience and demonstrated skill with data analysis and interpretation with ability to use analysis to inform QI and communicate results in both verbal and written formats in most appropriate manner based on target audience.
Extensive experience with quality improvement utilizing QI methodologies (e.g. The Model for Improvement, rapid cycle PDSAs, etc.) and other evidence-based strategies and techniques
Exceptional computer skills, particularly with Microsoft Office applications – Word, Excel, PowerPoint, Outlook, etc
Work requires a background generally equivalent to a bachelor’s degree in a business related field.
Work requires four years related business experience in healthcare business, management, healthcare legal affairs, institutional administration and/or related administrative fields
Degrees, Licensures, Certifications
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