Overview
Job Summary
Coordinates patient care through the integrating functions of case management, utilization review and management, discharge, and transition planning. Ensures quality, cost-effective utilization of resources consistent with the hospital mission, department goals and priorities. Directs the daily and short-range goal setting and planning for the assigned case type. Provides ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Overall goal of this position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness.
Essential Functions
- Case Management and Patient Care Evaluation: Serves as a liaison for health care team members in progressing the patient through the health care delivery system through facilitation, communication, and follow-up. Evaluates the patients? progress in achieving expected outcomes utilizing the Plan of Care/Routine Orders/Evidence based care standards. Evaluates patient's plan of care for assigned case type upon referral and throughout hospital stay and informs health care team of any deficiency. (avoidable delay tracking)
- Patient Screening: Screens/identifies patients requiring case management in designed specialty/assigned UM units using available resources through established case finding mechanisms.
- Physiological and Psychosocial Assessment: Assesses and identifies patient's physiological and psychosocial status and responses upon referral and throughout hospital stay. Completes assessment according to CM and hospital guidelines. Completes assessment according to CM and hospital guidelines. Gathers relevant, comprehensive information and data through interviews with the patient/family, physician, and other members of the interdisciplinary team. Pro-actively identifies patients/families with complex psychosocial/discharge planning needs.
- Care Planning and Patient & Family Education: Involves the patient and family in plan of care and discharge preparation upon referral and throughout hospital stay; Implements appropriate interventions based on the patient and family cultural, religious, and ethnic beliefs. Plans, organizes, develops care alternatives, facilitates, and monitors implementation of discharge plan and discharge teaching; updates discharge plan in collaboration with the healthcare team in accordance with patient clinical course and continuing care needs to expedite post discharge care. Coordinates plan of care with healthcare team to facilitate appropriate progression of care; and to ensure that critical elements have been communicated to the patient/family and all members of the team through patient care conferences and discharge planning activities.
- Care Coordination: Participates in daily Communication and Patient Planning (CAPP) meetings with physicians and the interdisciplinary team. Escalates to the appropriate member of the leadership team, clinical practice issues resulting in barriers to discharge. Participates in Complex Care Meeting (CCM) weekly and completes follow-up tasks as assigned. Communicates with the Utilization Manager to maintain up to date information about patient level of care status and to manage level of care transitions and discharge plans. Prioritizes observation patient care needs to assure timely progression of care. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, interdisciplinary team, third party payors, and resource center.
- Intervention: Maintains and assures adherence to applicable evidenced based clinical standard, practices, tools, and protocols to improve care progression and reduces LOS and resource consumption. Initiates and facilitates referrals through the support center for home health, hospice, DME, SNF, & rehab. Understands the intricacies of and can interpret with state, local, and federal agencies to optimize placement of patients in the most appropriate setting.
- Communication, Collaboration, Critical Thinking: Effectively communicates (verbal and written) with patient, family, interdisciplinary team, and third-party payor regarding treatment goals, care coordination, and discharge planning needs. Collaborates with peers and interdisciplinary team members to assure effective outcomes. Works with team to create solutions to take corrective actions to address issues resulting in variances in the plan of care. Documents all work in EPIC and other clinical information systems in a timely manner per departmental guidelines. Collects and enters avoidable days and patient alerts in Canopy. Consistently utilizes critical thinking skills in all aspects of work. Evaluates and modifies case management plan to meet changing needs of patient/family.
- Outcomes: Monitors appropriate outcome metrics such as length of stay, re-admissions, and avoidable days. Pro-actively develops strategies to improve outcomes related to pathway development, education programs, process improvements, etc.
- Chart Review and Documentation: Documents pertinent patient data in medical record and reviews documentation to ensure compliance with Professional Review Organization requirements (CMS, CCME, and TJC). Conducts chart review of Medicaid charts on Day One for Level of Care Orders and Medical Necessity. Conducts chart reviews of Medicare charts (select units, case type, or cross coverage) including review for medical necessity and Level of Care Orders. Assigns and conducts subsequent reviews (continued stay reviews) based on patient condition and medical necessity. Documents review process in Progress Notes and/or MIDAS (CERMe).
- Communication and Timely Reporting: Communicates pertinent patient data in medical record and reviews documentation to ensure compliance with CMS, CCME, and Utilization Review Plan. Utilizes Physician Advisors as needed (E.H.R.). Communicates possible non-coverage notice or patient discharge appeal. Interfaces with Physicians, Admitting, and Nursing Unit to ensure timely reporting and follow-up of appropriate level of care assignment. Reports any concerns about job duties, health care team communications, patient/family issues or physician issues as needed to Director.
- Teamwork: Collaborates with health care team in addressing complex patient/family needs. Maintains positive working relationship with members of health care team, Clinical Review staff, physicians, and serves as the utilization review and case management liaison for assigned units.
- Cost Effectiveness: Participates in evaluating and utilizing patient care products, equipment and resources in a cost effective, efficient and productive manner.
- Professionalism: Upholds a professional working relationship at all times and adheres to department rules. Practices teamwork and adheres to Standards of Behavior.
- Other Duties: Performs other duties as assigned by management.
Education
- Bachelors Nursing Required
- Masters Nursing Preferred
Experience
- 3+ Clinical Nursing Preferred
- 2+ Specialty Area Experience Preferred
Certifications, Licenses and Registrations
- Registered Nurse Required
- BLS required per policy guidelines
- Certification in specialty preferred
Additional Knowledge, Skills, and Abilities
- This position requires the successful completion of a pre-employment physical demands test.
- Successful completion of General Hospital Orientation provided by TCU and specific orientation to the Clinical Integration Coordinator role including two weeks under the direction of Director, Clinical Integration.
- Demonstrates competency in assessing, planning, implementing, and evaluating care including patient/family education and discharge planning for patients within assigned specialty.
- Demonstrated ability to facilitate team or group activities, knowledge of performance assessment principles and research process.
- Demonstrates leadership qualities including professional verbal and written communication skills, ability to be flexible and to prioritize in complex situations, decision-making skills, and professional development through participation in continuing education and professional organizations.
Physical Requirements
- Lifting 40 pounds from floor to waist
- Holding 12 pounds and lifting 6 pounds from waist to crown
- Lifting or carrying 55 pounds horizontally for 2 feet
- Pushing 80 pounds
- Pulling 100 pounds
- Front carrying 25 pounds a distance of 150 feet
- Dynamic push of 40 pounds minimum force over a distance of 160 feet
- Low work positioning at an occasional frequency
- Gripping 50 pounds with each hand
- Forward bending in standing for 5 minutes
- Rotation in standing
- Repetitive squatting
- Standing for 5 minutes
- Walking frequently
- Visual acuity required for accurately reading and documenting patient charts and observing patients
- Sense of smell required for safety issues
- Sense of touch is required to evaluate patient’s vital signs
- Ability to speak and hear is required to effectively communicate with patients, family members, physicians, and staff
- Manual finger dexterity for writing, equipment operation (maneuvering wheelchairs/beds), and positioning and moving patients
- Ability to effectively manage a high stress environment resulting from patient volume
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