Medication Management Care Coordinator

Position Status

Open

Site

Pittsburgh

NHC Position Type

Care Coordinator

Position Summary

The UPMC-Shadyside Family Health Center is a safety-net practice, caring for a large population of people of color and a medically underserved population. We are committed to providing excellent primary health care services to our patients, and excellent residency training to its post-graduate residents seeking to become Board Certified Family Physicians. The UPMC Shadyside Family Health Center is also home to additional clinical services and training programs with clinical pharmacists, including an accredited specialty program in outpatient primary care clinical pharmacy practice.

The AmeriCorps member will manage the center’s medication management-related registries in 3 areas (care transitions, HIV care, and adherence assistance), follow up with patients needing assistance with medications, and act as a team member with our clinic’s pharmacist faculty to assist patients with accessing care.

Patient unmet needs include education and advocacy in a complex, fragmented local medication management system. Patient require support to maintain or increase access to medications which are often expensive and fraught with complicated coordination steps. This position will have ongoing access to our patients with higher need for assistance in medication management and monitoring through weekly reviews with our primary care pharmacist practitioners in Tuesday clinics, as well as daily access through the transition of care, HIV care and med packing registries. This position sits within and collaborates with the entire primary care team at Shadyside, and cares for patients together with the entire  team, typically communicating through the shared electronic health chart, with some team activities by phone, virtual conference and face-to-face.

For work with our small panel of patients living with HIV, collaboration includes working with an HIV specialist physician, faculty family physicians, resident physicians interested in HIV care, a board-certified pharmacotherapy specialist pharmacist, and pharmacy residents, then bridging with the primary care physicians to help patients access important HIV-informed primary care outside of the HIV specialty care setting. Vulnerable populations impacted by the AmeriCorps Member involvement include patients with financial or system barriers to medication use, with many patients with insurance coverage gaps or receiving government-sponsored care including Medicare and Medicaid, patients with polypharmacy and high medical complexity, and patients living with HIV.

The UPMC-Shadyside Family Health Center is a safety-net practice, caring for a large population of people of color and a medically underserved population. We are committed to providing excellent primary health care services to our patients, and excellent residency training to its post-graduate residents seeking to become Board Certified Family Physicians. The UPMC Shadyside Family Health Center is also home to additional clinical services and training programs with clinical pharmacists, including an accredited specialty program in outpatient primary care clinical pharmacy practice.

The AmeriCorps member will manage the center’s medication management-related registries in 3 areas (care transitions, HIV care, and adherence assistance), follow up with patients needing assistance with medications, and act as a team member with our clinic’s pharmacist faculty to assist patients with accessing care.

Patient unmet needs include education and advocacy in a complex, fragmented local medication management system. Patient require support to maintain or increase access to medications which are often expensive and fraught with complicated coordination steps. This position will have ongoing access to our patients with higher need for assistance in medication management and monitoring through weekly reviews with our primary care pharmacist practitioners in Tuesday clinics, as well as daily access through the transition of care, HIV care and med packing registries. This position sits within and collaborates with the entire primary care team at Shadyside, and cares for patients together with the entire  team, typically communicating through the shared electronic health chart, with some team activities by phone, virtual conference and face-to-face.

For work with our small panel of patients living with HIV, collaboration includes working with an HIV specialist physician, faculty family physicians, resident physicians interested in HIV care, a board-certified pharmacotherapy specialist pharmacist, and pharmacy residents, then bridging with the primary care physicians to help patients access important HIV-informed primary care outside of the HIV specialty care setting. Vulnerable populations impacted by the AmeriCorps Member involvement include patients with financial or system barriers to medication use, with many patients with insurance coverage gaps or receiving government-sponsored care including Medicare and Medicaid, patients with polypharmacy and high medical complexity, and patients living with HIV.

Major Duties and Responsibilities

  • Identifying patients who are at-risk to assess eligibility for various services
  • Patients to confirm program enrollment and engagement
  • Providing follow-up and case management to deliver assistance and information
  • Implementing patient engagement strategies to improve outcomes
  • Maintaining professional boundaries and respecting patient confidentiality
  • Educating patients on medical interventions and prevention
  • Documenting interactions with patients in an electronic health record
  • Collaborating with supervisors and other leadership
  • Conducting program quality improvement and data analysis
  • In the space below, list other major duties. Note: Major duties represent at least 10% of the time on service.:
  • Interfacing with community pharmacies on behalf of patients

Characteristics of an Ideal Candidate

  • Multi-tasker; ability to balance
  • Detail-oriented
  • Positive attitude
  • Good verbal and written communication skills
  • Proficient computer and data entry skills (e.g., Microsoft suite)
  • Creative problem solving
  • Persistence
  • Non-judgmental

Highly desirable: initiative (proactive, engaged, speaking up without formal invitation) and strong follow-through. Helpful: flexibility, familiarity with the realities of system function/dysfunction throughout healthcare, especially with regard to cost and underinsurance for medication access.

Knowledge Required for the Position

  • Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options
  • Basic services available for medication management, function of insurance coverage for medications, how insurances authorize medicines, what formularies are and how to check them

Supervision

 

  • Member uses initiative in carrying out recurring assignments following set procedures, independently.
  • The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.
  • The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.
  • Depending on activity complexity, supervision will range from direct to indirect to available if needed. Expect high contact with supervising pharmacists throughout service period.

Review

  • The service activities are reviewed for accuracy through spot checks, through complaints from customers, and through observation of the Member at service.
  • The Member independently plans and carries out the projects and selects the approaches and methods to be used in solving problems.
  • Patient coordination will take place roughly daily. The Member will function on a team, with a mix of independent (some) and highly interdependent (most) activities.

Guidelines

  • Written and oral guides provide specific instructions for doing service.
  • Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards and files of previous projects.
  • Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.
  • Member must use considerable judgment in adapting current or developing new guidance.
  • Guidelines from years of training new care team members are available. Customizing to the new audience of future Members will be part of the initial Medication Management Care Coordinator set of responsibilities.

Complexity

  • Member has to develop, analyze, or evaluate information before the service position can progress.
  • The service position assignments vary significantly or often involve unusual circumstances and incomplete or conflicting data.
  • The Member must develop new techniques, methods, or approaches to complete service position assignments.

The Member will be reviewing information and making decisions about care escalation that do not fit a cookbook rubric. Every patient scenario is highly unique and the tools available (strategies to help with medication affordability, organization, appropriateness, support services) are subject to variation depending on patient specifics and eligibility. Creativity and flexibility will be emphasized, and task repetition will be low to low-moderate.

Purpose and Impact of Service Position Assignments

  • The Member’s service output is necessary in order to facilitate the service of other staff.
  • Service position assignments involve a variety of conventional problems, questions, or situations that conform to established criteria.
  • The service position product or service affects the design or operation of systems, programs, or equipment.
  • The service position product or services affect the social, physical, and economic well-being of a substantial number of people on an ongoing basis.
  • The Member is needed to enable a larger team to provide prospective services to patients with medication issues, rather than waiting for patients to present with complications.

Nature of Contacts

  • Public
  • Patients, care team members in the primary care office (nurses, front staff, physicians, physician residents), other health care professionals and institutions such as members of inpatient or outpatient care teams, pharmacies and insurances.

Purpose of Contacts

  • To give or exchange information
  • Occasional use of advocacy, persuasion and persistence in communication may be necessary when dealing with outside healthcare institutions or busy providers.

Special Considerations

  • Health screening or service required
  • TB testing, vaccination requirements

Criminal History Check Requirements Beyond NHC Standard Checks

In addition to NHC Standard Checks, all NHC Pittsburgh members are required to complete and pass criminal history checks for Great Lakes Behavioral Research Institute/Diversified Care Management (DCM). Great Lakes/DCM is a third party vendor contracted with the Allegheny County Health Department (operating site for NHC Pittsburgh) to distribute NHC Pittsburgh member stipends. NHC Pittsburgh members are onboarded to Great Lakes/DCM system only when the checks have been completed and the member has passed those checks. 

The checks that all NHC Pittsburgh members would be required to complete and pass for Great Lakes/DCM are the following: 1) Act 33 (Pennsylvania Child Abuse Clearance), 2) National Sex Offender Registry Clearance,  3) Act 34 (Pennsylvania Criminal History Clearance, and 4) Act 73 (FBI Criminal History Clearance - ONLY completed via Identogo PA).

NHC members do not have to pay for the completion of these checks. Great Lakes/DCM will distribute payment codes for the Act 33 (Pennsylvania Child Abuse Clearance) and Act 73 (FBI Criminal History Clearance which is conducted through Identogo PA ( PA FBI fingerprinting agency). The National Sex Offender Registry Clearance and Act 34 (Pennsylvania Criminal History Clearance) will be completed by Great Lakes/DCM upon receiving requested information that members will be asked to submit.