SUMMARY:

The Certified Diabetes Care and Education Specialist, in collaboration with the multidisciplinary team and in accordance with approved protocols, provides high quality patient care, Diabetes Self-Management Education and Support as well as disease prevention counseling services to patients/families with diabetes and those at risk for diabetes (pediatric, adult, and geriatric) across all sites and programs assigned by their supervisor. This includes coordinating care, assessing and identifying risk factors, negotiating care plans with the patient, education (group and/or individual), monitoring, communicating outcomes, and ensuring the care of their patients meets the organization’s productivity goals, quality performance measures, regulatory compliance, training needs, and research initiatives.

RESPONSIBILITIES:

• Provides quality, comprehensive care for diabetes patients, and those at risk for diabetes, through individual consults and group classes.
• Assess patient’s status (physical, psychosocial, environmental, self-care, educational needs, and home needs). Adjust intensity of service based on needs, and appropriate utilization of resources.
• Develop patient centered plan of care based on individualized patient needs. Utilize motivational interviewing, goal setting strategies and SMART goal development to promote realistic and successful behavior change.
• Uses self-management-training techniques, assess, plan and implement patient and family education in an individual and/or group setting. Education includes but is not limited to healthy eating, physical activity, self-monitoring blood glucose, taking medications, emotional adjustment and coping skills, foot care and risk reduction following the AADE 7 model. Evaluate the effectiveness of educational process toward achieving self-management. Refer when appropriate.
• Serves as resource for physicians in management of diabetes patients. Assists with medication adjustments to achieve optimal glycemic control in direct correspondence with the primary care provider, and/or endocrinologist.
• Identifies available community resources helpful to patients, refers and assists patients in utilizing such resources.
• Provides telephone triage and advice to patients as per agreement and direct correspondence with the primary care provider and/or endocrinologist.
• Consults with PCP and other members of the health team to present updates on patients and to ensure that procedures and systems are working effectively and efficiently.
• Completes documentation of patient status, plan of care, and progress.
• Demonstrates ability to interpret and maintain patient and site data.
• Participates in and contribute to the diabetes program by participating in quality improvement activities, attending department meetings, etc.
• Monitors monthly quality care reports generated by IFH stats & other available population management registries to review site quality metrics, track aggregate data and identify at risk patients to target for intervention
• Collaborates with other team members in planning and delivering appropriate patient care.
• Serves as resource for physicians, team members and site staff on diabetes care and workflows. Provides training and education as appropriate on diabetes specific clinical, procedural and technical aspects of care.
• Job specific competencies required: A1C & Glucose Point of Care Testing, Monofilament foot exams, pedal pulse, CDCES Competency Checklist

QUALITIFICATIONS

• Required: Bachelor's Degree
• Required: At least 2 years of relevant clinical experience working within diabetes education
• Required: Must have at least one of the listed licensures/certifications: Current NY State Registered Nurse (RN) or Certified Dietitian/Nutritionist (CDN) or Current Registered Dietitian/Nutritionist (RDN) for dietitians.
• Required: Certified Diabetes Care and Education Specialist
• Required: Current BCLS certification (required for Level I, II, and III)
• Required: Current Infection Control Certification (required for Level I and II)
• Master's Degree preferred
• Bi-lingual Spanish preferred

About The Institute for Family Health

The mission of the Institute for Family Health is to provide high quality, patient-centered primary health care in communities historically neglected due to racism and poverty, regardless of patients’ ability to pay.In support of this mission, the Institute:-Develops and operates community health care centers that provide primary care, behavioral health care, dental care and social services;-Trains physicians, nurse practitioners, dentists, behavioral health providers and additional health care professionals;-Commits to eliminating racism within our organization, and advocates for equity and justice by changing policies and practices that negatively impact our employees and patients;-Leverages health information technology to enhance the quality and efficiency of care, increase care coordination, provide patients with access to their health information, and communicate with the public health system;-Develops and sustains partnerships with community-based, faith-based and government organizations to address the critical clinical, social and economic needs of the communities we serve;-Engages in health services research and formulates policy related to primary care, behavioral health... care, dental care, social services practice, and education; and-Promotes workforce diversity, equity and inclusion and provides a work environment that encourages personal and professional development.

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Connections working at The Institute for Family Health