Care management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates plans of care designed to optimize patient's health care across the care continuum. It includes empowering patients to share in the decision making process, exercise their options for treatment and access the services appropriate to meet their individual health needs. The role of Care Manager requires one to have advanced clinical knowledge, as well as highly developed communication and interpersonal relationship skills.
Collaborates with physician and practice staff in identifying appropriate patients for care management
Meets with all patients identified for the MCMG RN Care manager- assess, engage in setting goals, and follow-up as appropriate
Meets with patients newly diagnosed with a chronic disease to ensure patient understands their disease process (medications, nutrition, exercise)
Documents plan of care in Centricity so all members of the team understand the plan and work together with the patient to achieve outcomes
Provides patient with plan of care and goals
Uses teach-back methodology to educate patients/families about medications, side effects and key concepts for disease management
Utilizes motivational interviewing skills to promote and encourage behavior change.
Provides clinical triage support to MA's and office when calls require an RN's expertise
Mentor other clinical staff by leading daily huddles and regular staff meetings, acting as a resource for clinical questions, and providing/coordinating ongoing education sessions for staff
Takes the lead role on the care management team by facilitating regular IDT care management meetings (at least bi-weekly)
Conducts care management assessments (using team developed tool) to determine where patient needs are best met (CCT, PHO, BHI, Social Work)
Tracks the number of patients actively engaged in care management, including who the primary care team is
Contacts patients after any ED/Hospital visit to identify patient is safe and there is little/no risk of a return visit. Provide education where needed and determine if the visit was avoidable/unavoidable
Tracks the number of patients seen in the ED, including whether the visit was avoidable/unavoidable
Actively participates in hospital case management meetings on a regular basis
Actively participates in continuing education opportunities related to care management and transition of care
Develops relationships and works with community partners (CHANS, CCT, Senior Spectrum, Tobacco Help Line, Mid Coast Health line, Center for Weight Loss) to break down barriers that impede patient progress toward goal achievement.
RN Degree. Must be willing to commit to BSN program enrollment within 1 year of hire.
2 years clinical experience
Current Maine licensure.
Current Basic Life Support (BLS) certification
Parkview Adventist Medical Center