Nurse Care Manager Chronic Disease

MAJOR FUNCTION:

The LPN Nurse Care Manager is responsible for providing relationship-centered, evidence-based chronic disease care management services to patients with multiple chronic conditions, high comorbidity burdens, complex healthcare needs, or elevated risk for adverse health outcomes. Using nursing knowledge, therapeutic communication, and evidence-based care management strategies, the LPN Nurse Care Manager supports patients in understanding and managing their chronic conditions, developing sustainable self-management behaviors, adhering to prescribed treatment plans, and accessing appropriate healthcare and community-based resources.

Working collaboratively with primary care providers, registered nurses, behavioral health professionals, pharmacists, community health workers, specialists, and other interdisciplinary team members, the LPN Nurse Care Manager facilitates coordinated, patient-centered interventions designed to improve clinical outcomes, increase patient engagement, close care gaps, and reduce preventable emergency department utilization and hospitalizations.

The position emphasizes patient education, chronic condition monitoring, behavioral change support, care plan implementation, transitional care coordination, and ongoing evaluation of patient progress.

The LPN Nurse Care Manager utilizes a structured nursing process, within the scope of practical nursing practice, to identify changes in patient health status, reinforce individualized care plans, implement authorized interventions, and communicate findings to the supervising RN or authorized provider.

ESSENTIAL RESPONSIBILITES

• Patient Identification, Risk Stratification, and Enrollment
• Utilize electronic health records, population health registries, risk stratification reports, and provider referrals to identify patients who may benefit from chronic care management services.
• Prioritize outreach to patients with multiple chronic conditions, high-risk clinical indicators, frequent emergency department utilization, recent hospitalizations, or significant barriers to healthcare access.
• Conduct initial patient outreach to explain care management services, assess interest, and facilitate enrollment in applicable programs.
• Review available patient medical histories, active problem lists, prescribed medications, preventive care gaps, and healthcare utilization patterns.
• Identify patient-reported concerns, healthcare access barriers, functional limitations, and social needs that may interfere with effective chronic disease management.
• Collaborate with the RN, primary care provider, and interdisciplinary team to determine appropriate care management interventions and levels of support.
• Maintain an assigned caseload and prioritize patient engagement based on clinical risk, established protocols, and individual needs.
• Nursing Assessment and Identification of Care Needs
• Conduct structured patient interviews and collect clinical, functional, behavioral, and social information within the LPN scope of practice and established protocols.
• Obtain and document relevant patient-reported symptoms, vital signs, medication adherence concerns, health behaviors, and barriers to following treatment recommendations.
• Identify changes in patient condition, emerging risk factors, or potential complications requiring timely clinical evaluation.
• Review available clinical information, including relevant laboratory results, screening findings, and provider recommendations, to support established care management activities.
• Identify patient knowledge gaps related to chronic conditions, medications, treatment recommendations, and self-management.
• Evaluate patient readiness to change, health literacy, personal goals, available support systems, and potential barriers to engagement.
• Communicate significant findings, concerning symptoms, and changes in condition to the supervising RN or authorized provider according to established escalation protocols.
• Contribute collected findings to the comprehensive nursing assessment and individualized care planning process led by an RN or authorized provider.
• Individualized Care Planning and Care Plan Implementation
• Collaborate with the RN, primary care provider, patient, caregiver, and interdisciplinary team to implement individualized, patient-centered care plans.
• Contribute patient information, identified barriers, self-management goals, and recommended coordination activities to care plan development.
• Reinforce established care plan goals, prescribed treatment recommendations, and patient-specific instructions.
• Assist patients in identifying realistic, measurable self-management goals that support improved health behaviors and chronic condition management.
• Implement assigned nursing and care coordination interventions consistent with approved care plans, standing protocols, and clinical direction.
• Monitor and document patient progress toward established goals, including adherence, appointment completion, symptom reporting, and behavior change.
• Recommend care plan review or modification to the RN or authorized provider when patient needs, barriers, or clinical circumstances change.
• Ensure patients and caregivers understand their established care plans and know how to access appropriate assistance.
• Maintain accurate and current care plan documentation in the designated electronic health record or population health management system.
• Chronic Disease Management and Monitoring
• Provide ongoing support for patients with chronic conditions, including but not limited to diabetes, hypertension, cardiovascular disease, heart failure, chronic obstructive pulmonary disease, asthma, obesity, and other conditions identified by the care team.
• Conduct scheduled patient follow-up by telephone, telehealth, or in person to monitor treatment adherence, reported symptoms, self-management activities, and changes in healthcare needs.
• Reinforce provider-established disease management goals and individualized treatment recommendations.
• Refer patients to patient-reported home measurements such as blood pressure, blood glucose, weight, and other condition-specific programs.
• Identify trends or findings outside established clinical parameters and escalate concerns to the appropriate licensed professional.
• Support patients in understanding warning signs, recommended follow-up, and when to seek urgent or emergency medical attention.
• Collaborate with providers to facilitate recommended laboratory testing, follow-up visits, specialty services, and preventive screenings.
• Assist with identifying and addressing care gaps associated with chronic disease management and organizational quality measures.
• Promote proactive management of chronic conditions to reduce complications and avoidable healthcare utilization.
• Patient Education, Health Coaching, and Behavioral Change Support
• Establish trusting, therapeutic relationships that encourage patient engagement, shared decision-making, and active participation in care.
• Reinforce individualized patient education concerning chronic disease processes, medications, nutrition, physical activity, symptom monitoring, and preventive care.
• Utilize motivational interviewing, teach-back, goal setting, and trauma-informed communication techniques to support health behavior change.
• Assess patient understanding of established treatment recommendations and identify opportunities for additional education or clinical clarification.
• Support patients in developing practical self-management strategies consistent with their abilities, preferences, and treatment goals.
• Monitor progress toward agreed-upon behavioral goals and assist patients in identifying strategies to overcome barriers.
• Reinforce appropriate medication adherence, home monitoring practices, and recommended follow-up.
• Promote patient confidence, activation, health literacy, and sustained engagement in chronic disease self-management.
• Recognize and respond appropriately to emotional, behavioral, or social factors that affect chronic disease management.
• Medication Management Support and Adherence
• Review patient-reported medication use and prescribed medication lists to identify potential discrepancies, adherence barriers, or concerns requiring further review.
• Reinforce provider and pharmacist instructions regarding medication purpose, administration, and adherence.
• Identify barriers such as cost, pharmacy access, transportation, medication complexity, or difficulty understanding instructions.
• Facilitate prescription refill requests, pharmacy communication, and access to medication assistance resources as appropriate.
• Communicate suspected adverse reactions, discrepancies, medication-related symptoms, or treatment concerns to prescribing provider.
• Support medication reconciliation workflows following hospital discharge or transitions of care, with final clinical review and authorization performed by the appropriate licensed professional.
• Document medication-related concerns and follow-up activities in accordance with organizational protocols.
• Care Transitions and Hospitalization Prevention
• Identify and engage assigned patients following emergency department visits, inpatient admissions, hospital discharges, or transitions between care settings.
• Conduct timely post-discharge outreach in accordance with organizational protocols and applicable care management program requirements.
• Review available discharge instructions and reinforce the established transition plan with patients and caregivers.
• Assist with scheduling post-discharge appointments and coordinating recommended follow-up services.
• Identify barriers to obtaining prescribed medications, durable medical equipment, home health services, and other necessary resources.
• Communicate unresolved discharge needs, medication concerns, or changes in health status to the RN or treating provider.
• Coordinate with hospitals, rehabilitation facilities, skilled nursing facilities, specialists, and community-based organizations to promote continuity of care.
• Support implementation of interventions intended to reduce avoidable emergency department utilization, hospital readmissions, and gaps in post-discharge care.
• Care Coordination, Advocacy, and Community Resource Navigation
• Serve as a consistent point of contact for assigned patients and facilitate communication among patients, caregivers, primary care providers, specialists, and community resources.
• Coordinate follow-up appointments, specialty referrals, diagnostic testing, and recommended preventive services.
• Identify social determinants of health affecting patients' ability to manage chronic conditions.
• Facilitate referrals to community health workers, social workers, behavioral health professionals, nutrition services, transportation programs, and other appropriate resources.
• Advocate for patients experiencing barriers to accessing medically necessary services.
• Collaborate with interdisciplinary team members to address complex medical, behavioral, functional, and psychosocial needs.
• Promote continuity of care and effective communication across healthcare settings.
• Escalate unresolved service barriers and clinically significant concerns to the appropriate team members.
• Chronic Care Management, Population Health, and Quality Improvement
• Support implementation of organizational chronic care management and population health initiatives.
• Complete required patient contacts, follow-up activities, and care coordination interventions according to established protocols.
• Document eligible care management services, including service dates, activities, duration, and relevant clinical information, in accordance with organizational and payer requirements.
• Support applicable Chronic Care Management (CCM), Principal Care Management (PCM), Advanced Primary Care Management (APCM), and other approved programs when assigned.
• Assist with identifying and closing care gaps related to applicable HEDIS, UDS, payer-specific, and value-based care quality measures.