Case Manager-Ed

Case Manager-Ed

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Summary:

• Ensure collaboration among multiple parties; the patient, family and the multi-disciplinary team (internal and external stakeholders), which may include the payer in an effort to facilitate and coordinate services specific to the patients' needs during a stay in the Emergency Room and post-discharge needs or as an admission to the hospital. All case manager activities will be client-centric, performed in a proactive manner, require on-going assessment of needs, evaluation of resources, knowledge of associated costs and education as indicated. The case manager is responsible for presenting options in an unbiased fashion to all involved parties and in compliance with HIPAA. Empowerment of the patient or healthcare proxy is expected and maintained so an informed decision regarding continued care needs can be made. Advocacy and education are at the heart of all activities with the basic goal focused on providing best clinical outcomes possible for the patient through evidenced based practice.

Responsibilities:

• Utilization Management: Evaluate the need for discharge and evaluate level of care being provided utilizing utilization criteria and methodologies (i.e. XSOLIS). Utilize hospital resources appropriately and in a cost-effective manner. Contact, collaborate and coordinate with various payers per contractual expectations regarding beneficiary's entry into Doylestown Health care continuum and subsequent transition to various levels of care within or external to our care continuum; working closely with the payer care manager to ensure an optimal outcome for the patient. Ensure admission order is constructed correctly on every admission. All data elements must be addressed: Diagnosis, reason for admission, estimated length of stay and appropriate level of care (Inpatient or Observation), Will utilize the physician advisors and manager as a resource when indicated; for cases not meeting medical necessity criteria.
• Discharge Planning: Assessment and evaluation of the patient needs will be conducted by reviewing current and prior functioning, psycho-social dynamics, and identification of support system. The discharge plan is developed in collaboration with the multi-disciplinary team which may include the payer and will include active input from the patient and/or family. Identification of barriers must be considered in order to facilitate a smooth and successful transition to the next level of care. The case manager will address issues with prior plan of care, specifically with regards to readmissions. Review of insurance benefits will be conducted to ensure most appropriate next level of care services identified, can speak to any co-pays/deductibles, identify potential barriers to care as related to cost and offer options specific to needs. Determine patient needs and resources through interview and record review. Discharge planning process includes coordination and collaboration with the patient or the patient's decision-maker to provide relevant information regarding financial resources, insurance benefit limitations and identify tentative discharge plan. During the interview process the case manager will familiarize the patient to their role, and potential care options. Care options and providers/agencies could include but not limited to the following: rehabilitation care, nursing home, personal care, hospice services, home care agencies and community resources. Patient or healthcare proxy will be provided the "options" list of providers to choose services from and will be asked to make a decision at time of admission of shortly thereafter to expedite next level of care needs. Discharge planning includes facilitating a collaborative environment inclusive of both internal and external stakeholders to include but not limited to the following entities: physicians, therapists, nurses, payer, any outside resources pertinent to next level of care and of course, the patient and family. All parties will be working together to achieve the best outcome and discharge plan specific to the patient's needs and wishes. Advocacy for patients who no longer can independently advocate for self will be the responsibility of the case manager. This may include mediation and facilitation with multi-disciplinary team or family. Serve as a resource to provide information and direct intervention to resolve problems and / or obstacles that impede the provision of high-quality, cost-effective care. Coordination of care post-hospitalization may include discussions with primary care physician regarding discharge planning to the acceptable level of care (return to the same facility, no psychosocial issues) and/or refer to the appropriate community resources (WIC, food stamps, HRSA- medical assistance, etc.). Coordinate plans for post-discharge care with a focus on age specific needs or special population needs and requirements. Completion of requisite documentation in both Allscripts and Meditech regarding discharge plan, discussion and concurrence of plan with multi-disciplinary team, patient and family and in compliance with all regulatory guidelines. All readmission assessment and identification activities will be completed as outlined in department policies. Participate in multidisciplinary collaboration in development and implementation of treatment plan, and secure authorization for needed additional patient services as required. Verify insurance benefits in planning post-discharge care.
• Implementation and facilitation of care activities: The case manager will act in a proactive manner addressing real and potential issues with the development and implementation of the plan of care. Documentation of the case manager's activities and discussions should be outlined in the patient's medical record. This might include but is not limited to reaching out to external stakeholders such as the primary care provider and requesting assistance with the development of the plan of care. The purpose would be to overcome any identified barriers to care with the goal being to achieve a successful outcome for the patient. Additionally, the case manager should be verifying benefits and securing authorizations from the payer as indicated and documentation should include facilitation of necessary community resources as needed. Advocacy is an important aspect in the case manager's role as he/she must take into consideration the patient's ability to safely maintain themselves in the community or when the patient's capacity is in question. The case manager needs to ensure the patient or healthcare proxy has the ability to fully understand the options of care being presented so an informed decision can be made. Also, this could include acting as a mediator between physicians/consultants and families when conflict arises or a change in status occurs that may put up road blocks to a successful transition to the next phase of care. During the initial assessment phase the case manager will identify potential barriers to a safe, smooth and seamless discharge. Review of current and past records may be needed to identify past medical history or contributing factors to the patient's illness or re-hospitalization. The case manager will be required to complete their due diligence in order to identify additional assessments that need to be completed beyond the initial assessment. Respect and support the patient's Right for Self-Determination and Freedom of Choice. Objectively present all options and alternatives with associated risks, benefits, and information to assist the patient or healthcare proxy in the informed decision making process. Maintain collegial and collaborative relationships throughout the care continuum. Providing outreach to community provider as indicated is an expectation to ensure an optimal outcome for the patient. Proactively consulting and collaborating with internal and external stakeholders as indicated whether calling the practitioner or payer or requesting consults with various disciplines i.e. physical therapy, nutrition or psychiatry as indicated is an expectation. Documentation of all activities and efforts to provide a safe discharge is required. All documentation should be completed in Allscripts and Meditech to insure appropriate communication of plans and activities to all concerned parties and in the event of litigation. This would include but is not limited to patient/healthcare proxy choice, referrals to chosen aftercare providers, CM Final disposition, and any other notes. Responds to requests for consults and educational materials (elder law, advance directives) in a timely manner and in accordance with established department standards (within one working day). Maintain a working knowledge of laws such as the Pennsylvania Mental Health Procedure Act, Child Protective Services Laws, Pennsylvania Adoption Law, Act 148, Patient Self Determination Act, OBRA and Older Americans Act. Identification of patients who appear to lack capacity to make an informed decision about their care needs. It is incumbent upon the case manager to request an evaluation for capacity when their mental status is in question or no POA is identified. Consulting and notifying director and Risk Management are required. If lack of capacity is confirmed then representation for any subsequent court proceedings may be required. Assistance with any guardianship issues is expected. Maintain accountability of assigned caseload is expected.
• Data Collection: Case Manager will participate in the collection of information regarding quality improvement activities, risk management issues and reporting this information through appropriate committee structure. Maintain knowledge base of current Case Management theory and practice to include quality and regulatory initiatives. Maintain knowledge base of clinical practice guideline development, utilization, and measurement. Participate in the prioritization and development of practice guidelines and committees whose focus is on improving the overall care and outcomes for our patients. Monitor care practices in relation to accepted standards of practice at Doylestown Hospital and regulatory entities (state and federal). Identify and act on variances which would include notification of your supervisor etc. Collect information regarding quality improvement activities and risk issues, and report this information through the appropriate channels.
• Behavioral Expectations: Exhibit consistent professional conduct in interaction with patients/families, medical staff, payers and peers while also respecting HIPAA requirements. Takes ownership for errors and takes immediate corrective action when indicated. Maintain high standards of professional conduct. Demonstrate respect for medical staff, administration, colleagues, customers, and self. Facilitate open communication and work to achieve positive, productive relationships with internal and external stakeholders. Demonstrate ability to effectively prioritize work in