- Develops a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients.
- Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals.
- Works as a team with other members of care management, including but not limited to: RN Care Managers, assistants, coordinators, utilization management staff, and director.
- Facilitates communication among all treatment team members.
- Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
- Updates the care team, patient/family as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired.
- Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
- Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
- Monitors risk assessment using available tools and implements discharge interventions accordingly.
- Actively addresses and monitors resource utilization and documents delays as appropriate.
- Identifies patients with an unplanned readmission and completes root cause analysis.
- Coordinates utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission.
- Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.
- Provides supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitates the decision making process in Complex Cases.
- Facilitates resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate.
- Act as resource to the staff for regulatory issues regarding discharge-planning and psychosocial processes.
- Uses electronic systems to accurately document Care Manager functions.
TRAINING AND EXPERIENCE:
Preference is for at least two years of experience as an RN or Social Worker in an acute hospital setting. Previous care management experience is preferred. Strong critical thinking skills. Ability to maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships. Knowledge of medical terminology required. Ability to communicate both verbally and in written forms. Basic computer skills required.