- Works closely with clinic physicians to address patient issues (therapy goals, vocational interests/goals, and patient financial status) as they arise in clinic setting.
- Works with patient and family to develop a mutually acceptable plan of care to maximize the potential of the patient, family, and community.
- Coordinates physician orders to outside suppliers, including home health, durable medical equipment, and supplies.
- Manages requests for medication assistance, forms, and letters that come to the outpatient case management office.
- Acts as liaison between the patient/family/ clinical team/ECM/ outside vendors to assure open communication regarding clinical and cost information.
- Completes regular rounding opportunities and yearly evaluations on CMA’s.
Accountabilities, Outpatient:
- Works closely with clinic physicians to address patient issues (treatment plan, therapy goals, vocational interests/goals, and patient financial status) as they arise in clinic setting.
- Works with patient and family to develop a mutually acceptable plan of care to maximize the potential of the patient, family, and community.
- Communicates to patients about community based resources and programs.
- Coordinates language services when interpretation needs arise in the clinic.
- Coordinates physician orders to outside suppliers, including home health, durable medical equipment, and supplies.
- Manages requests for medication enrollment, financial assistance, forms, and letters that come to the outpatient case management office.
- Acts as liaison between the patient/family/ clinical team/ECM/ outside vendors to assure open communication regarding status and financial information in the patients plan of care.
- Completes regular rounding opportunities and yearly evaluations on CMA’s.
- Understand new patient intake processes for Outpatient clinics and provide assistance as needed.
- Understand ethical considerations, patient in crisis in relation to finances, neglect, abuse, psychosocial needs, etc.
Accountabilities, Transition Support:
- Attend interdisciplinary team meetings to determine patient care
- Collect patient health data prior to discharge home via team meeting, EMR review, conversations with the referring CM and primary RN.
- Meet with the client/family post-DC to explain the role and function of the Transition Support services
- Work closely with clinic physicians to address patient issues (therapy goals, vocational interests/goals, and patient financial status) as they arise in clinic setting.
- Work with patient and family to develop a mutually acceptable plan of care to maximize the potential of the patient, family, and community.
- Communicate to clients/caregivers about community based resources and programs.
- Continue the coordination of physician orders to outside suppliers, including home health, durable medical equipment, and supplies.
- Manage requests for medication assistance, forms, and letters.
- Provide education, guidance, and support post discharge, with a strong focus on medical, financial and psychosocial needs.
- Assist clients and caregivers in determining personal goals that lead towards improved long term health and safety outcomes, as well as community reintegration and a meaningful life post injury.
- Develop and implement a plan of care that prescribes interventions to attain the expected outcomes.
- Refer to TSP LST, as appropriate
- Complete thorough and accurate documentation in electronic records.