Clinical Transitions Spec RN Wknd - CMH IP Clin Case Mgmt

Case Manager

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of Carle Health. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. Utilizes the five components of case management: assessment, coordination, monitoring, implementation, and evaluation.

Act as a liaison working with patient/family and physician to determine next level of care and manage LOS. Coordinates the transition from inpatient care to post-hospital care, collaborating with physicians, consultants, internal and external referrals to facilitate appropriate next level of care to meet patient goals and outcomes. Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients. Evaluates effectiveness of plan of care and collaborates with physicians to ensure the progression toward desired patient outcomes while managing risk for readmission and length of stay. Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider. Initiates intervention, both pre-hospital, in-hospital, and post-hospital, for patients and families identified from a proactive initial admission assessment, as well as through referrals from members of the healthcare team. Participates in multidisciplinary rounds and initiates timely referrals to other internal healthcare team members (quality improvement, risk manager, social workers, pharmacy, therapy services, etc.) Performs case management activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education. Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs. Conducts case review presentations to educate peers on unique or challenging cases and scope of practice issues. Track avoidable days on inpatient stays. Readmission assessment of inpatient stays. Assess patients for post discharge needs within 24-48 hours of admission and ongoing throughout the stay. Assess patients risk for readmission and navigate strategies with patient and family to reduce risk through post acute planning. Arrange DME, Home Care, outpatient infusion and coordinate with social work for Hospice, ECF Placement, and Transportation Deliver or delegate delivery of regulatory letters for Medicare and observation patients. Arrange/attend any patient/family care conferences.