RN Case Manager PD

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

40

• Work in a collaborative practice model, facilitating care coordination with the multidisciplinary treatment team for care progression to optimize patient outcomes and timely discharge when patient is deemed medically ready.

• Provide case management assessment and interventions based on initial screening for discharge needs, identify readmission risks, patient strengths and needs related to transition and discharge planning; collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, ongoing evaluation, and medical readiness for discharge.

• Oversee and coordinate complex medical discharge planning needs for assigned patients in collaboration with other interdisciplinary team members, assuring a safe discharge plan is developed and implemented in a timely manner; proactively identifies and resolves delays and obstacles to discharge.

• Collaborate with providers and all members of the multi-disciplinary team to manage the clinical resources and transition planning for patients within assigned caseload from admission through discharge, actively working to identify/eliminate barriers to deliver of services required to advance care and promote timely discharge based on medical readiness; facilitate the following on a timely basis:

  • Completion and reporting diagnostic testing,

  • Completion of discharge plan,

  • Modification of plan of care, as necessary, to meet the ongoing needs of patient,

  • Completion of all required documentation in APeX flowsheets and patient records

• Coordinate and lead multi-disciplinary rounds (MDRs) and monitor discharge milestones, assign accountability for tasks, and proactively identify and address/ escalate barriers to timely discharge when medically ready.

15

• Ensure that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.

• Consider age specific needs of the patient as appropriate and effectively communicates and interacts with patients, families, staff and members of the community from diverse backgrounds.

15

• Refer appropriate cases for social work intervention

• For patients with significant or intensive psychosocial needs, serve as the secondary care manager, working in close collaboration with the social worker to bring nursing scope of practice and expertise to address the holistic needs of the patient.

15

• Monitor patients’ length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient’s clinical and psychosocial needs.

• Initiate and facilitate referrals through the Resource Coordinators for post-acute care resources (i.e. home health care, SNF, rehab facilities, hospice, medical equipment and supplies).

• Oversee and direct activities delegated and performed by the Resource Coordinator and/or Patient Care Navigator.

10

• Participate in clinical performance/quality improvement teams within the department, service lines, and hospital to identify opportunities for improvement in such areas as clinical outcomes, length of stay management, and utilization of resources; use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.

• Provide consultation and education to members of the healthcare team, hospital departments, service lines and community agencies and providers.

• Initiate and lead the development, implementation, evaluation and revision of clinical pathways and other case management tools as a member of the clinical resource/team.
• Participate in department program planning including goal setting, program development, systems development and improvement. Participates on department and hospital committees and task forces

5

• Demonstrate competency with work-required computer programs and incorporates use into daily work routine.

• Demonstrate the ability to interpret data and trends using appropriate analytical skills.

• Oversee and direct activities delegated and performed by the Support Liaison.

100%

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