Case Manager- CMH Care Facil And Util Mgt

• Care Coordination

• Screens 100% of adult Medical Surgical In-patient and observation patients and assesses the individual's health status including clinical conditions, support systems and resources to identify needs and make referrals to appropriate multi-disciplinary services.

• Prioritizes patients for care coordination based on defined criteria.

• Monitors and coordinates an interdisciplinary plan of care in partnership with the individual and their support services for needs and services across the health care continuum and for transition through the levels and locations of care.

• Assumes accountability for the development and implementation of an effective discharge plan for complex care patients. Works with internal and external resources to co-ordinate a timely safe transition of patient to the appropriate level of care.

• Leads and participates with the interdisciplinary team in daily rounds, planning delivery and evaluation of patient-focused care for prioritized patients.

• Documents the case management plan to include: clinical needs, barriers to quality care, effective utilization of resources and pursues denials of payment and referrals in a timely, legible manner.

• Completes tighter integration with ambulatory care management team, especially with high risk, chronically ill patients.

• Standardizes alert to cross continuum care managers when patients are admitted

• Works closely with providers for discharge planning and determining the next level of care

• Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge

• Collaborates with Utilization Management team on continued stay review.

• Discharge Planning

• Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge

• Identifies and facilitate post-acute resource needs: Home Care, Community based Referrals, Diagnostic testing, Outpatient Therapies (Pulmonary Rehab, Cardiac Rehab, Physical and/or Occupational Therapy), Palliative Care or Hospice.

• Ensures that the patient's degree of vulnerability has been captured and documented on the Transitions of Care report.

• Ensures verbal communication with the ambulatory / cross continuum care manager regarding patients who have moderate or red vulnerability at transition.

• Documents who will assume the care coordination/management role for these patients and for what period of time in the Common Care Plan and the Transition of Care report, if known.

• Reviews the predictive tool for readmission and document the risk for readmission. Implement additional interventions to mitigate the risk for readmission such as two follow-up appointments - one at the time the predictive tool indicates the patient is at highest risk for readmission

• Utilizes the med -to-bed program for patients with poly pharmaceuticals

• Education* Communicates patient/family learning needs that surface to the direct care nurse. Collaborate with direct care nurse on education plan.

• Refers to content experts as appropriate i.e. wound care team, Diabetic Educators, Respiratory Therapy or PT.* Documents education related to medication adherence

• Facilitates patient self-management education.

• Revenue Cycle

• Demonstrates a working knowledge of financial and reimbursement processes to facilitate medical cost management, including best practices, effective utilization of resources, linking clinical and financial aspects of care, and access to care and level of care.

• Serves as a resource and educator to patient, family, staff and physicians regarding financial aspects of individual patient's resources which may affect the transition of patients through the healthcare system.

• Provides education for the individual and family and for the team regarding benefits, utilization of resources, levels of care, and expectations of the transition process throughout settings across the healthcare

The RN Case Manager integrates and coordinates the clinical care of individuals. Facilitates the interdisciplinary plan of care in order to meet multiple service needs, promotes continuity through elimination of fragmentation of care/service and facilitates the effective utilization of resources. Serves as educator and a central source of communication for the individual and their support systems.