Addressi
- Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
- Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
- Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.
- Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
- Document any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.
- Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.
- Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
- Send referrals/communicate with in-network vendors for coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute and Acute Rehab.
- Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.
- Assure follow up appointments and referrals to ambulatory case manager for high-risk patient population are scheduled and communicated to patient/family prior to discharge.
- Observe all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)
- Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
- Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
- Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.
