RN CARE MANAGER - TRANS - HOME HEALTH - FT - DAYS - SHEA
September 29, 2018
Job Summary This position is an integral member of the case/care management team, working with patients and their families to assure a smooth transition following discharge from the hospital. This position works collaboratively with the various partners, leadership, providers, care coordinators and other health care professionals/agencies to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum.
The Transitional Care Manager RN collaborates with patients/caregivers early prior to and/or post- discharge. Key areas of focus include:
Establish relationship with patient/caregiver
Ensure PCP follow up within 7-14 days post discharge
Assess readmission risk and barriers to care outpatient including home support, medication management, expectation, etc.
Coordinate with hospital case manager regarding discharge plans
Provide effective communication of clinical information and plan of care between all care providers
Conduct effective post-hospitalization telephonic monitoring, or depending on the tier level of each case and risk for readmission.
Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific "red flags" of complications
Communicate effectively and professionally using all modalities i.e. technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise.
The Transitional Care Manager will facilitate a smooth and timely transition from acute care back to the appropriate primary care office.
Coordinates follow-up care with PCP and practice Care Manager /health coach(office based or centralized) regarding outpatient follow-up appointment and plan of care
Communicates key information regarding inpatient stay and discharge plans to patient's PCP/office care manager/health coach.
Assures effective transition and final hand-off to the patient's PCP and his/her office based care manager/health coach.
Coordinate with (employee plan) or Payer Care Management regarding support desired/required.
Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.
Maintains accurate metric tracking for daily productivity management.
Performs other duties as assigned.
Internal Number: 2018-12552
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