Job Objective/Purpose

The Chronic Care Lead Nurse performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Chronic Care nurse works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision- making.

Key Responsibilities

Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner.

Responsible for registry of chronic care management (CCM) to patients.

Validates enrollment of CCM patients based on provider request

Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR.

Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.

Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.

Facilitates patient access to appropriate medical and specialty providers.

Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates

Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education

Educates patient and family/caregiver(s) about relevant community resources.

Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.

Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.

Supports patient self-management of disease and behavior modification interventions.

Provides patient health counseling, education and instruction.

Any other duty assigned by your immediate supervisor in line with the job description.

Person Specification

Graduate of an accredited nursing school as a Registered Nurse with a valid license with the Nursing Council of Kenya.

Updated BLS, ACLS/ATLS certificate

Minimum of 3-6 years work experience in a healthcare setting involving patients with complex chronic disease states preferred.

Customer focus, empathetic and emotional intelligence

Strong interpersonal and communication skills

Organizational awareness and attention to detail

Team work and result oriented

Ethical and reliable