Job Summary The Transitional Care Manager RN is an integral member of the care management team, working with patients and their families to assure a smooth transition following discharge from the hospital. This position works collaboratively with the Chief Medical Officer, providers, hospital based specialists, Care Coordinators and other health care professionals/agencies to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum.
The Transitional Care Manager RN collaborates with patients/caregivers early in the inpatient episode in preparation for discharge. Key areas of focus include:
Establish relationship with patient/caregiver
Assure PCP is aware of patient's admission
Assess readmission risk and barriers to care outpatient including home support, medication management, expectation, etc.
Coordinate with hospital case manager regarding discharge plans
Monitors and reviews cases that are in the emergency room; facilitate the notification of network providers if patients utilize the ER. Participate and support the ED Staff with the patients most appropriate setting for care.
Provide effective communication of clinical information and plan of care between the Hospitalist, Emergency Room Physician, Specialists, and PCP; as well as other key healthcare providers involved in the case.
Conduct effective post-hospitalization telephonic monitoring, or depending on the tier level of each case and risk for readmission.
Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific "red flags" of complications
The Transitional Care Manager will facilitate a smooth and timely transition from acute care back to the appropriate primary care office.
Coordinates follow-up care with PCP and practice Care Manager /health coach(office based or centralized) regarding outpatient follow-up appointment and plan of care
Communicates key information regarding inpatient stay and discharge plans to patient's PCP/office care manager/health coach.
Assures effective transition and final hand-off to the patient's PCP and his/her office based care manager/health coach.
Coordinate with (employee plan) or Payer Care Management regarding support desired/required.
Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.
Communicate effectively and professionally using all modalities i.e. technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise.
Performs active listening, uses motivation interviewing and open ended questioning techniques and guided care goal setting for the patient.
Maintains all regulatory educational requirements participating in continuing education and quality improvement activities. Demonstrates professional behavior and promotes cooperation and team building
Demonstrates technical skill and new forms of technology in maintaining clear and professional clinical documentation in software data base for cases followed under transition and for case assignment.
Supports and participates in the development and maintenance of Scorecard. Maintains accurate metric tracking for daily productivity management.
Maintains and manages to their caseload
Performs other duties as assigned
Internal Number: 2019-15755
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