Case Manager (InPatient)
* Provides clinical consultation as a Registered Nurse (RN) with the Patient Care Team to facilitate coordination of care across the continuum for selected complex patients.
* Partners with Patient Care Team; maintains accountability for the delivery of patient care and oversees care throughout patient's admission and return to community setting as applicable.
* Key responsibilities include, but are not limited to, case finding and assessment, patient/family education and advocacy, resource management and discharge planning in an acute care, long-term care setting, or community setting, as assigned.
PRIMARY DUTIES AND RESPONSIBILITIES:
ASESSMENT AND CASE FINDING
* Utilizing diagnostic and cost criteria, conducts a preliminary assessment (pre-admission if possible) to determine patient's complexity and need for case management intervention.
* In conjunction with Patient Care Team, performs admission and ongoing assessments.
* Identifies special patient and family needs as well as age-specific requirements.
COORDINATION OF CARE ACROSS THE CONTINUUM
_In collaboration with patient/family: _
* Communicates with patient/family in development of implementation of care plan. Identifies a point person from the family.
* Assesses and communicates regarding advanced directives/power of attorney/issues of legal status.
_In collaboration with care team:_
* Confers with delivery care team regarding patient condition, care delivery needs, utilization of resources, discharge needs.
* Utilizes objective data gathered through assessment and patient examination to develop a plan of care that identifies immediate, short- and long-term care needs. Initiates referrals as needed.
_In collaboration with physician:_
* Based on established goals, identifies and re-directs care and treatment to ensure appropriate care and cost-effective outcomes.
* Collaborates with physician regarding patient progress, discharge plans. Participates in clinical rounds with physician. Notifies physician of change in patient status.
* Clarifies, reviews and obtains phone orders from physician.
* Facilitates communication between primary physician and other physicians.
* Participates in and implements investigational protocols.
* Collaborates with physician and team to prevent available readmissions.
* In collaboration with Patient Care Team develops and coordinates discharge plan.
* Identifies post-discharge care needs and makes referrals for community services.
* Conducts post-discharge follow up, including any follow up phone calls regarding questions/concerns.
* Coordinates with Community Referral Specialist actions pertaining to nursing home placement and community referrals; collaborates with community partners to promote successful coordination of care for patients upon discharge from acute care setting as applicable.
* Ensures appropriate level of care has been determined; re-directs care and treatment to ensure appropriate care and cost-effective outcomes.
* Integrates and utilizes factors related to quality, safety, efficiency and cost-effectiveness in planning.
* Provides clinical information to payors as needed or requested and to ensure re-certification.
* Communication with physician regarding level of care, resource plan and payor requirements.
* Participates in research findings in development of policies, procedures and guidelines for cost-effective, high- quality client care.
_In collaboration with Professional Caregiver:_
* Assesses patient/family learning needs and styles.
* Communicates with patient/family/primary caregiver regarding condition and plan of care.
* Develops and coordinates education plan for patient, including but not limited to Discharge Teaching - assesses for understanding/independence:
* identifies needs, develops plans, and teaching tools
* performs initial teaching
* monitors progress and reinforces learning
ADVOCATES FOR PATIENT/FAMILY NEEDS
* Responds to and resolves patient/family concerns/complaints.
* Provides bereavement support.
CORE VALUES/PROFESSIONAL STANDARDS:
* Demonstrates The Queen's Health Systems' core values of Compassion, Aloha, Respect and Excellence.
* Complies with all organization policies and procedures, applicable laws and regulatory requirements.
TYPICAL PHYSICAL DEMANDS:
* Essential: sitting, finger dexterity, seeing, hearing, speaking, lifting usual weight of 5 pounds, pushing/pulling usual weight of 50 pounds, carrying usual weight of 10 pounds.
* Frequent: standing, walking, reaching above, at and below shoulder level, repetitive arm/hand motions.
* Occasional: sitting, stooping/bending, kneeling, crawling, climbing stairs, walking on uneven ground, squatting, twisting body, lifting and carrying weight up to 20 pounds, pushing/pulling weight up to maximum 50 pounds of force.
* Operates various office and audiovisual equipment.
TYPICAL WORKING CONDITIONS:
* Not substantially subjected to adverse environmental conditions.
* Exposed to medications, radiation, body fluids, sharps, communicable diseases,
* electrical/mechanical units and chemicals.
* Work schedule includes weekends and holidays as assigned. Work environment may be stressful due to multiple requests/projects and priorities.
EDUCATION/CERTIFICATION AND LICENSURE:
* Bachelor's degree in Nursing.
* Current Hawaii state license as a Registered Nurse.
* Current CPR certification at BLS/HCP level.
* Current certification as a Certified Case Manager (CCM) through CCMC preferred.
* Two (2) years healthcare experience as a Registered Nurserequired: acute care long-term care, or community settings may be required according to clinical are assigned