The Long Term Supports and Services Supports Coordinator works within a team environment partnering with the Care Coordinator (RN) to advocate and coordinate the continuum of care for our patients. This role requires a high level of interaction with our patients to:
- Perform effective outreach to complete necessary health and social assessments
- Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social)
- Support the patient in achieving their own goals as stated in the care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs
- Work with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient’s needs and promotes positive health outcomes.