Address
Form of workJOB PURPOSE OR MISSION: The Care Coordinator position encompasses the process of case management practice in partnership with the medical staff and members of the clinical team accountable for outcomes of selected patient populations. The Care Coordinator is accountable to the patient and the community and is responsible for facilitating the patient's safe, cost efficient, progression-of-care throughout the entire episode of acute care and assuring the patient's timely and seamless transition back to the community.
PERFORMANCE CRITERIA
CRITERIA A: Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of the job.
PERFORMANCE STANDARDS:
Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
Takes initiative in living our Everyday Excellence values and vital signs.
Takes initiative in identifying customer needs before the customer asks.
Participates in teamwork willingly and with enthusiasm.
Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
Keeps customers informed, answers customer questions and anticipates information needs of customers.
CRITERIA B: Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.
PERFORMANCE STANDARDS:
Practice's diligence in fulfilling the regulatory and legal requirements of the position and department.
Maintains accurate and reliable patient/organizational records.
Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.
CRITERIA C: Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.
PERFORMANCE STANDARDS:
Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
Upholds the ethical standards of the organization.
CRITERIA D: Performance Improvement - Employee actively participates in Performance Improvement activities quality improvement standards in his/her job performance.
PERFORMANCE STANDARDS:
Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
Initiates or redesigns to continuously improve work processes.
Contributes ideas and suggestions to improve approaches to work processes.
Willingly participates in organization and/or department quality initiatives.
CRITERIA E: Cost Management - Employee demonstrates effective cost management practices.
PERFORMANCE STANDARDS:
Effectively manages time and resources.
Makes conscious effort to effectively utilize the resources of the organization - material, human, and financial.
Consistently looks for and uses resources saving processes.
CRITERIA F: Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.
PERFORMANCE STANDARDS:
Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
Employee proactively reports errors, potential errors, injuries or potential injuries.
Employee demonstrates departmental specific patient and employee safety standards at all times.
Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures, and plans.
JOB FUNCTIONS
ESSENTIAL JOB FUNCTIONS include, but are not limited to:
1. Facilitates triple aim initiatives by ensuring access to appropriate care.
PERFORMANCE STANDARDS
Advocate for patient by assessing that patient healthcare needs are being addressed in the most appropriate level of care.
Understands and works in all hospital settings for patient coordination or care, such as the emergency department, ICU, Burn unit, Women & Infant, med/surg/telemetry, etc.
Screens patients to determine appropriate level of care coordination interventions based on risk factors related to barriers that impact progression of care, transition of care, and readmissions.
Assesses patient situation by collecting information from patient and family, professional and non-professional caregivers, employers (as appropriate), and health records to identify individual needs to develop a comprehensive progression-of-Care Management plan and assessment that will address those needs.
Confirms admission diagnosis and identifies related quality metrics to promote medical compliance.
Partners with the medical team to participate in developing a medical treatment plan appropriate to the patient's level of care and preferences.
Encourages and facilitates patient/family participation in all care and treatment decisions.
Educates members of the patient's healthcare team on the appropriate access to and use of various levels of care.
Recognizes and responds appropriately to risk factors.
2. Implements a wholistic and patient driven approach to Care Management.
PERFORMANCE STANDARDS
Assess the effectiveness of services and their outcomes in concert with the interdisciplinary team, recommending appropriate plan modifications to assure treatment objectives are met.
Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
Provide point-of-care coaching to medical documentation that accurately reflects intensity of services, quality and safety indicators, and patients' response to treatment.
Consults with medical advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, external case managers, and post-acute providers.
Facilitate and coordinate patent and family meetings to discuss goals of care, difficult treatment recommendations, new diagnosis, etc.
Facilitate complex psychosocial assessments and brief counseling on such topics as fetal demise, teen pregnancy, new cancer diagnosis, complex medical treatment needs, wound/burn care, trauma, guardianship, return to home barriers, goals of care, advanced directives, etc. as they impact patients' hospitalization.
3. Orchestrates the coordination of care throughout the patient continuum.
PERFORMANCE STANDARDS
Serve as primary liaison between and among physicians, patients, families, payers, external case managers, post-acute providers, and interdisciplinary clinical team.
Maintain appropriate documentation on each patient to include specific documentation of all planning, liaison, and coordination activities.
Collaborates with post-acute coordinators to monitor and facilitate the progress of completing discharge logistics.
Pro-actively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources.
Meet with patient and family as appropriate to provide update on treatment plan, obtain their input and develop realistic, obtainable discharge goals.
Maintain contact with patient, family, payer, and/or post-acute provider regarding initial assessment, progress, changes in condition, approval for special procedures, equipment, other services, and upcoming discharge.
Assess, consult, communicate, and facilitate a resolution regarding patient's social service resource needs, anticipated psychosocial issues, negative family dynamics, financial constraints, palliative care, psychological or hospice needs.
Assess, consult, and communicate to the interdisciplinary team social determinants of health and risk factors that could impact patients' successful transition and/or potential likelihood for risk of readmission.
Actively participate in daily huddles, patient care conferences, and hospitalist/nurse's hand-off reports to gather sufficient information to determine the effectiveness of the treatment plan and patient care goals.
4. Steward of resource management
PERFORMANCE STANDARDS
Identify, organize, and secure the resources necessary to accomplish the goals set forth in the patient's treatment plan.
Facilitate the timely delivery of services to patients and families through effective management and utilization of available resources
Interface with utilization reviewers to stay current on patient's eligibility for admission, continuing stay or readiness for discharge.
Persevere in attempts to influence clinical and financial outcomes of care.
Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
Understands and applies federal law regarding the use of HINNs, ABNs, Important Message from Medicare (IM), Medicare Outpatient Observation Notice (MOON), and discharge appeal rights.
Evaluate patient care outcomes to determine the effectiveness of the treatment plans clinical and financial effectiveness.
Assertively manage resource utilization while appropriately navigating the patient's movement along the continuum of care.
Collaborate with attending and hospitalist physicians to influence appropriate utilization of resources and transitions from one level of care to another.
5. Coordinates a safe and timely transition of care for appropriate patients.
Advocate for the patient to expedite progression-of-care and ensure appropriate level of care.
Makes timely referrals to the Post- Acute Resource Center to expedite post-acute service arrangements.
Collaborate with nursing and members of the clinical team to provide patient/family education regarding discharge goals that require the team's expertise (medication administration, transferring to/from a car, oxygen use, etc.)
Research discharge placement options, when home discharge is not possible, while continuing to focus on patient/family goals, interdisciplinary team recommendations, available payer benefits and private financial considerations which may impact placement
Assure discharge plan is addressed during daily rounds, keeping patient/family objectives in mind while modifying the plan as appropriate and posting on the patient's white board.
Update all involved parties regarding progress, revisions and other information related to transition readiness.
Facilitate referrals to local, state, and federal resources and arranging patient/family counseling or support groups after discharge.
6. Provides supervision for nursing students, undergraduates, CSW/LMSW interns as appropriate.
Mentors' undergraduate and/or nursing students
Reviews documentation of CSW/LMSW interns
Meets supervision requirements for CSW/LMSWs in accordance with the Louisiana Social Work Practice Act and Louisiana Administrative Code, Title 46, Part XXC.
7. Performs all other duties as assigned.
