Care Transitions RN Case Manager

Essential Functions:

The RN Case Manager collaborates with the health care team to develop the plan of care and patient flow.

Tasks:

• Reviews all cases within 24 – 48 hours or the next business day of admission/bed placement and each day throughout the stay to facilitate care progression to establish an anticipated length of stay and transition planning needs.
• Collaborates with the medical team to formulate a treatment plan to include care transitions and promote patient flow.
• Completes an initial assessment of all admissions/observation patients to identify barriers that impact the length of stay and discharge planning. The assessment should also identify the needs of the patients, acknowledge current resources available, and anticipate future resources needed to facilitate successful transitions.
• Navigates the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults, and procedures are appropriately indicated and performed timely.
• Articulates the plan of care and communicates this plan to other care team members and patient/caregiver. Intervenes to maintain care progression when a deviation in the plan occurs.

Influences positive outcomes by communicating the plan of care, expected discharge date, and transition needs to the patient/caregiver and team, thereby enhancing patient and staff satisfaction.

Tasks:

• Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver.
• Participates in daily multidisciplinary rounds incorporating evidence/best practice milestones in the plan and communicates that plan to the health care team.
• Apprises the interdisciplinary team of the estimated length of stay, care progression barriers, and anticipated disposition. Identifies what is needed from the team to facilitate the plan.
• Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to proper post-acute providers are initiated.
• Communicates the plan effectively with the patient and family/caregiver making certain that they have resources for success post-discharge.

Understands organizational goals for the length of stay and unplanned readmissions.

Tasks:

• Identifies appropriate clinical guidelines and directs the care plan to establish the anticipated length of stays and appropriate patient status.
• Proactively interfaces with the payer, where required, verifying coverage/benefits for anticipated discharge needs.
• Identifies patients that are at readmitted or at high risk for unplanned readmissions and initiates appropriate interventions. Identifies organizational resources within the community and engages those resources as necessary.
• Documents avoidable days (if not captured by another Care Transitions Team member), case management assessments, and care plans in a thorough and timely manner, per department policy.
• Ensures appropriate care provider documentation to support the patient’s anticipated discharge plan of care. Escalate deviations from the plan to the Physician Advisor as appropriate.

Possesses effective verbal and written communication, relationship-building techniques, and negotiation skills.

Tasks:

• Completes clear and concise documentation of the care plan and communicates this to the interdisciplinary team and the patient-caregiver.
• Identifies and communicates any problems or issues affecting patient flow, patient satisfaction, safety, length of stay management, or outcomes to the department director and/or appropriate key stakeholder.
• Functions as a resource for governmental and health care industry regulations and ensures compliance, communicates standards to the interdisciplinary team.
• Informs the patient and family/caregiver of the plan of care and the plan progression. Facilitates communication with the providers and encourages open dialogue.

Maintains current knowledge of organizational policies, care transitions, and clinical trends, as well as regulatory requirements for clinical care, discharge planning, and authorization for post-acute services.

Tasks:

• Attends and contributes to departmental staff meetings.
• Participates and contributes to multi-disciplinary committees and other committees or workgroups as directed.
• Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, and readmissions while suggesting strategies to improve organizational/departmental performance.

Contacts:      Regular contacts, within or outside BILH, to give or get information.

Require courtesy, tact, and some knowledge of BILH procedures.

Education Required:

RN licensure in the state of Massachusetts