Case Manager RN

Care Coordinator

The Care Coordinator is responsible for ensuring patient progress and meeting and facilitating a safe and sustainable transition plan. Collaborates with Physician and Interdisciplinary Team to determine plan of care, treatment, estimated LOS, and likely discharge disposition (home, LTAC, SNF, or ALF). Ensures that Physician/Interdisciplinary Team discusses estimated LOS, tentative discharge date, and assessed needs for discharge with the patient and family. Reviews medical record to anticipate clinical stability and to have a thorough understanding of the patient prior to speaking with the physician and/or participating in multidisciplinary rounds/huddles. Participates in interdisciplinary Rounds or Huddles.

Ensures patient is progressing through clinical milestones and adjusting the targeted discharge day as indicated. Collaborates with Interdisciplinary team members to continuously identify more effective strategies to resolve barriers, improve processes and systems, and change practice as indicated. Escalates barriers to the plan of care (clinical, social, and environmental) through appropriate channels to resolution. Works in partnership with physicians to consider alternate levels of care if patient is not meeting acute care criteria. Facilitates communication among physicians caring for patient to advance plan of care. Monitors and documents avoidable days and documents anticipated discharge date in medical record for all patients. Plans medical discharge needs.

Collaborates with Social Work to manage the needs of patients who have high acuity psychosocial needs coupled with need for medical post-acute care to ensure successful reintegration into the community and to mitigate risk for readmission. Supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases. Responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital.

In addition to the above duties, the Emergency Department (ED) Care Coordinator (CC) provides hand-off communication to acute care staff, directs patient assignments to appropriate admitting/Hospitalist service, leads consultation regarding appropriate bed placement, and identifies and diverts unnecessary admissions from ED to community-based providers. ED CCs identify recidivistic patients and work with Social Work and community-based providers to decrease ED over-utilization. Creates, implements, and updates Patient Specific Action Plan (PSAP) on ED frequent utilizers, communicating PSAP to all members of the Interdisciplinary Team with each admission to the hospital. Identifies and ensures documentation of conditions that may be "present on admission."

Duties and Responsibilities:

1. Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record.
2. Holds, interprets, and integrates the patient's story into the overall multidisciplinary plan of care.
3. Coordinates/facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target LOS.
4. Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting.
5. Uses the Physician Advisor per protocol for complex issues related to physician practices or behaviors. Determines next steps for the patient and physician with the Physician Advisor.
6. Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds.
7. Actively participates in clinical performance improvement activities as assigned.
8. Builds a network of positive working relationships that advocate for the patient.
9. Conduct team meetings for all unplanned readmissions that occur within 30 days.
10. Complete whatever paperwork is necessary to facilitate the patient's transition through levels of care.

Graduate of accredited School of Nursing; Associates Degree Required, licensure to practice as a Registered Nurse by the State of Florida. Five (5) years nursing experience with at least two (2) years in Case Management or two years in Emergency Medicine.