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By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.
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Provide health education on wellness, disease prevention, chronic care management and self-management skills to patients and personal support persons, based on the documented expertise or professional training of the PACT member.
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The Primary Care Nurse Practitioner diagnoses and treats diseases and injuries and delivers preventive and therapeutic treatment of Veteran patient primary care needs, including chronic disease management through routine history and physical examination testing and non-invasive treatment.
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Physician Assistantor· APRN License Type/Certification:o AGPNP/ANP (Adult Gerontology Primary Care NP or Adult NP): Adult pts (13 years to death), stable chronic disease state management or primary care setting.
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The goal of the Chronic Care Management program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.
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Develop and promote preventive care outreach programs to educate patients on common health topics including HIV/AIDS, infection control, sexually transmitted disease, hepatitis, diabetes, hypertension, obesity, and chronic disease management.
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Must have expertise in managing hematological complications of sickle cell disease (i.e., acute chest syndrome, stroke), expertise in chronic pain management, and expertise in prescribing disease-modifying therapies.
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Track quality assurance data and monitor for acute and chronic care management. Educate patients and families about health status, health maintenance, and management of acute and chronic conditions.
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With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx.
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Duties include but may not be limited to wound care, including NPWT/VAC, Peg/Trach Care Management, Foley insertion and catheter care management, JP/PleuRx Drain care, administering injections.
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The Licensed Clinical Social Worker will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound judgement.
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We are a pioneer in telemedicine and population health, including innovative chronic disease management programs for hypertension and diabetes. Family Medicine inpatient and outpatient care with strong staffing support.
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Wound Nurse Responsibilities: Wound Assessment and Management: Conduct thorough assessments of patients with complex wounds, including pressure ulcers, surgical wounds, and chronic ulcers, and develop individualized care plans for treatment and prevention.
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Assesses and manages psychological issues for patients entering the chronic pain program which will be done at an individual level and in a group setting and consults with other departments as needed for co-management of care.
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This includes a focus on medication reconciliation and adherence, management of member's quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, support of member's ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum.
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