Detailed responsibilities:
- PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
- IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
- DATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate
- ASSESSMENT - Assess the patient's clinical, psychosocial status and current treatment plans
- NEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources
- ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment
- REPORTS & RECORDS - Maintain computer-based tracking system and compile required reports and records
- COLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities
- GOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members
- PLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
- DISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team members
- VARIANCES - Intervene when variances occur in patient individualized treatment plan
- RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
- INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary
- VARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategies
- TREATMENT CONFERENCE - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management
- EDUCATION - Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control
- INFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team
- CONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant others
- MEETINGS - Participate in team meetings when indicated or as directed
- CARE PLAN - Incorporate recommendations and/or services of interdisciplinary team members in the care plan
- COMMUNICATION - Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfaction
- DOCUMENTATION - Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely manner
- ORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriate
- QUALITY - Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentation
- COMMITTEES - Attend meetings and represent department or Hospitals within Hospitals related committees or the community, as assigned by supervisor
- DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
- PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
- PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
- PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
- PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
- PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
- MEDICATION - (UPC and CPC Only) Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings
- PATIENT CARE - (UPC and CPC Only) Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions