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Transitional Care Program Manager/Case Manager - (full-time)

Category:

Nursing and Nursing Administration

Description:

The Transitional Care Program Manager/Case Manager (TCPM), along with the Medical Director, provides Transitional Care Program leadership including implementation, care coordination, marketing and quality assessment. The TCPM is knowledgeable of program processes and clinical guidelines, implements program components, ensures staff are fully trained, provides program and clinical leadership, oversees and coordinates patient care from pre-admission through discharge, and is actively involved in all program and quality measures.

The Transitional Care Program Manager/ Case Manager adheres to the ACMA Standards of Practice and Scope of Services (located at http://www.acmaweb.org/section.aspx?mn=&sn=&wpg=&sid=22)

Minimum qualifications:

  • Graduate of an accredited School of Nursing, BSN required.
  • Current Washington state RN license.
  • One (1) year experience in utilization review/quality improvement. Practical experience in discharge planning preferred. Experience and/or knowledge of DOH rules and regulations for custodial swing bed required.

Primary job responsibilities:

Program Implementation and Development Responsibilities

  • Knowledgeable of Transitional Care Program processes and clinical guidelines (evidenced by completion of pertinent Allevant on-line and on-site education/training)
  • Provides leadership role in implementing all Allevant-provided care guidelines, training and education (evidenced by ensuring completion of training modules and unit-based competencies)
  • Monitors Transitional Care program quality measures and supports the development of action plans as needed to improve program processes and outcomes
  • Learns and utilizes A3 problem-solving techniques as appropriate

Marketing

  • Participates in marketing and referral development activities
  • With Allevant support, identifies and develops new product lines to meet the needs of the community served
  • Develops strong relationships with acute care hospital discharge planning staff within referral region

Provides Leadership for Transitional Programs

  • Provides important formal and informal leadership for the Transitional Care program
  • Is recognized by care team, administration and patients/families as essential leader

Staff Training, Education, and Expertise

  • Orients new employees to Allevant-provided education and training requirements
  • Ensures that all clinical staff complete education/training and are competent in program clinical skills
  • Provides and/or arranges for “just in time” education and training, as needed, to improve or further develop staff competencies to support Transitional Care program
  • Ensures that clinical/program resources are available and accessible to staff to include: clinical and process guidelines, Allevant on-line clinical resources, Allevant-provided Learning Management System (LMS) education requirements and opportunities
  • Ensures Respiratory Therapy and Rehab Therapy are aware of quality reporting requirements and monitors timely/accurate quality data entry

Patient Care: Support of Clinical Care from Pre-Admission Through Discharge

Pre-admission

  • Assesses appropriateness of all referrals
  • Works with physician, providers and Transitional Care Team members to ensure team can meet patient and family needs
  • Works with discharge planning from acute care hospitals to establish skilled nursing or therapy service that will qualify patient for admission
  • Ensures appropriate payer source for admission has been identified
  • Works with insurance and payers to ensure transitional care stay is covered
  • Understands Medicare skilled nursing and therapy requirements to meet coverage
  • Identifies risks for readmission and helps mitigate those risks along with care team members

Within three days of admission (ideally within two days)

  • Engages and educates patient and family on expected discharge plan
  • Patient and/or family present during initial care coordination conference
  • Schedules bedside rounds with care team and patient/family
  • Ensures discussion of discharge and barriers during rounds

Weekly during stay:

  • Identifies risks associated with harm or likelihood for hospital readmission
  • Identifies risks during initial care conference and subsequent bedside rounds
  • Ensures risks are addressed and interventions/plans documented in the medical record
  • Records data regarding performance on the Transitional Care Bundle in Allevant quality- reporting portal

Within one week of discharge:

  • Ensures team discussion (may be bedside round) with patient/family - Patient and/or family present for discussion of discharge? Discussion of barriers to discharge and interventions to address? Has education/training of patient and family been completed for patients going home? Does patient/family have any questions or concerns regarding discharge? If so, what are they?
  • Ensures outpatient providers are prepared to continue care, as needed
  • Ensures referrals are made to outpatient and continued care providers
  • Schedules follow-up care appointments, as needed
  • Ensures future transportation needs are addressed, as needed

Day of discharge (no more than two days before actual discharge):

  • Ensures clear and concise discharge and medication instructions are prepared
  • Ensures discharge instructions documented
  • Ensures primary nurse and/or physician have discussed discharge instructions and follow-up care with patient/family
  • Ensures patient/family are able to accurately communicate their discharge plan, medications and follow-up care
  • Assesses patient/family for questions or concerns regarding discharge or follow-up and addresses if necessary

Within 3 days post discharge:

  • Ensures timely follow-up with patient/family and outpatient care providers
  • Completes follow-up phone call with patient/family within 72 hours of discharge Does patient/family have any questions/concerns?
  • Utilizes copy of discharge instructions to validate
  • Correct use of medications
  • Contact made or visit scheduled for Home Health, Physician/s, Rehab therapies, as recommended
  • Previously identified safety risks are appropriately managed based upon instructions and training provided
  • Ensures expedited discharge summary sent to outpatient providers

Program Components: Ensures that the following program components are in place and functioning properly:

  • Transitional Care Bundle
  • Mobility Program
  • Bedside Rounding
  • Safe Patient Handling (Bariatric Patients)
  • Patient Safety Program

Program Metrics

  • Ensures collection of pertinent quality metrics and entry into Allevant quality reporting portal

Care Coordinator Backup

  • Establishes back-up registered nurse and trains in responsibilities for times when TCPM is absent
  • Other appropriate duties as assigned

Standard for portrayal of mission and values

  • Employee demonstrates and fosters the Lewis County Hospital District No. 1 values of achievement, creativity and innovation, teamwork, quality, and integrity.
  • Employee demonstrates and fosters the mission of Lewis County Hospital District No. 1 to provide our highest level of compassionate, diligent and professional medical care.
  • Is cooperative and supportive to others within the department and hospital providing care and services.
  • Treats individuals including patients, co-workers, supervisors, management, patient families, physicians, volunteers, visitors and others with respect, dignity and fairness.
  • Behaves professionally and ethically in all interactions with patients, co-workers, supervisors, management, patients' families, physicians volunteers, and others.
  • Is consistently courteous to patients, co-workers, supervisors, management, patient’s families, physicians, volunteers and others; greets individuals and provides assistance and direction in an attentive and helpful manner.
  • Willingly strives at continuous quality improvement to achieve quality work the first time every time.
  • Is willing to learn new procedures and develop new skills for the purpose of improving quality of care and services.
  • Willingly participates as a member of work team(s) supporting the goals and objectives of the department and the district.
  • When answering the telephone, is courteous to caller, clearly identifies department, name and takes a message or directs calls as necessary in a helpful manner.

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