- Completes a face to face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care and to anticipate high level care planning needs. Screens high risk patients with lace score greater than or equal to 10 to reduce 30 day readmissions. Consults with attending physicians regarding potential care transition barriers identified as a result of this process.
- Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage the length of stay.
- Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions.
- Provides an Important Message notice and choice on Medicare patients as appropriate.
- Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines.
- Monitors and facilitates appropriateness of tests/procedures, consultation, treatment plans and resource utilization.
Care Coordination, Collaboration, and Transition Planning
- Collaborates with social workers for patients with complex, clinical, financial and psycho-social needs.
- Reviews physician orders and patient progression on a daily basis and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary.
- Actively participates in multi-disciplinary rounds, long stay rounds and meetings that promote comprehensive and coordinated care plans and monitors progress against goals
- Provides clear and timely information on the patients plan of care to the next provider
- Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Maintains contact with the patient, family, physician, and team members to ensure the most cost effective plan of care is being carried out and appropriate in network providers are being utilized.
- Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase
- In accordance with established clinical guidelines/standards of care establishes a comprehensive care transition plan and will organize, secure, integrate and modify resources necessary to meet the goals stated in the assessment plan.
- Documents plan of care and updates /changes in plan of care in the electronic medical record.
- In collaboration with the appropriate services, arranges home care, DME and infusion and/or post acute services in partnership with the social worker. Maintains good working relationships with community providers
- Assists with medication issues for patients on an as needed basis.
- Serves in obtaining legal guardianship, competency determinations, adoption related situations and all cases where Adult or Child abuse is a concern. Is responsible for making sure all legal documents are completed. Collaborates with the Corporate Director and Manager of Case Management as needed.
- Provides counseling and support as needed. Identifies cases which would benefit from palliative care and elicits palliative consults as needed.
Education and Professionalism
- Serves as a resource to patients, physicians, Administration, and other disciplines regarding care management functions and expertise.
- Participates in defining, maintaining and interpreting care management standards of practice
- Assesses and educates patients and families on community agencies and resources
- Educates and reinforces the early identification of changes in patient condition and changes in care transition plans
- Assumes responsibility for own professional growth and is willing to share knowledge with coworkers and other health care providers.
- Performs assigned work safely, adhering to established departmental safety standards rules and practices; reports to supervisor , in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients, and visitors
- Maintains performance, patient, and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook.
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH Health System policies and procedures.
- All other duties as assigned.