To identify high-risk patients, I would leverage data analytics tools to analyze clinical, claims, and social determinants of health data. By stratifying patients based on chronic conditions, hospitalization history, and socioeconomic factors, I can pinpoint those needing targeted interventions. Collaboration with care teams to review patient histories and predictive modeling would further refine risk identification. This proactive approach ensures timely care coordination, reducing avoidable hospitalizations and improving outcomes.

Building trust is key. I would use motivational interviewing techniques to understand their concerns and barriers, such as financial limitations or lack of social support. By actively listening and tailoring the care plan to their unique needs, I can foster collaboration. Educating them on the benefits of adherence and connecting them with community resources can also increase engagement. Empathy and persistence help overcome resistance, ensuring patients feel empowered in their health journey.

In my previous role, I collaborated with physicians, nurses, social workers, and specialists to create seamless care plans. I facilitated regular team meetings to discuss patient progress, address gaps, and adjust interventions. Using EHR systems, I ensured all stakeholders had real-time updates. This teamwork improved patient adherence and reduced duplicate services. Effective communication and shared accountability were critical in achieving positive health outcomes for complex cases.

Success is measured through key metrics like reduced hospital readmissions, improved chronic disease management, and patient satisfaction scores. I track outcomes using dashboards to monitor trends and identify areas for improvement. Cost savings from avoided ER visits and preventive care uptake also indicate effectiveness. Regular feedback from patients and providers ensures the program remains patient-centered and adaptable to evolving needs.

Health literacy is vital for patient empowerment and adherence. I assess literacy levels through conversations and standardized tools, then tailor education using plain language, visual aids, and teach-back methods. Providing culturally relevant materials and involving family members when appropriate enhances understanding. By addressing literacy barriers, I ensure patients can make informed decisions, leading to better self-management and long-term health improvements.