- Perform ongoing clinical and psychosocial assessment of new patients, providing reassurance and building rapport.
- Identify and address barriers to care as reported by patients or the care team.
- Reduce care gaps, such as missed appointments and medication management, through frequent personalized engagement.
- Assess the need for and educate patients on remote health monitoring equipment.
- Respond timely to abnormal diagnostic results including labs and radiology.
- Assess urgent concerns and proactively triage patients to ensure appropriate use of emergency services.
- Document all care and interactions timely and escalate to multidisciplinary teams as needed.
- Contribute to program and product development by providing user feedback.