Ohana Pacific Health

Community Health Worker

• Support patients with navigating and accessing health and community services
• Carry out treatment goals or care plans created by advanced practice providers (APPs)
• Assist patients in improving healthcare access and promote knowledge of health and behavior change
• Support patients with community referrals and arrange follow-up services
• Collaborate with APPs to develop patient treatment goals related to wellness, access to care, engagement with health resources and services, and self-management of conditions
• Respond to patient inquiries and assist with paperwork
• Facilitate remote visits between patients and providers using telephone or video conferencing
• Educate patients on care processes and provide counsel to reduce anxiety and fear
• Identify barriers to care, including financial, transportation, insurance, and language barriers, and refer patients to additional resources
• Provide transition-of-care support, health education, chronic condition management, and social services assistance through a culturally relevant approach
• Provide services primarily in-person in hospital and short-term rehabilitation settings, and in the community in person or telephonically according to patient preference and needs

• Support carrying out treatment goals or care plans created by an advanced practice provider (APP)
• Assist patients in improving healthcare access and promote knowledge of health and behavior change
• Support patients with community referrals and arrange follow-up services
• Collaborate with APPs to develop patient treatment goals related to personal wellness, access to care, engagement with health resources and services, and self-management of conditions
• Respond to patient inquiries and assist with paperwork completion
• Facilitate remote visits between patients and providers using telephone or video conferencing
• Educate patients on care processes and provide counsel to reduce anxiety and fear
• Identify barriers to care, including financial, transportation, insurance, and language barriers, and refer patients to additional resources
• Provide transition of care support, health education, chronic condition management, and social services assistance
• Deliver services primarily in person in hospital and short-term rehabilitation settings, and in the community in person or telephonically according to patient preference and needs

Nurse

• Ensure timely completion of accurate MDS assessments, care plans and electronic MDS transmission for residents
• Coordinate the Interdisciplinary Team (IDT) team in development of the RAI process in accordance with federal and state regulation
• Review, edit, correct, and ensure assessments are signed appropriately, signifying completeness and accuracy of all MDS, CAA's, care plans and care conference notes
• Maximize reimbursement and resident-centered quality of care delivery based on best-practice standards of care
• Ensure accurate capture of resident acuity and complete documentation of services provided through accurate MDS review

Community Health Worker

Community Health Worker

Minimum Data Set Coordinator, LPN