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
- SUPERVISION - Develop efficient organizational structure. Supervise employees and select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
- 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
- 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
- ASSIGNMENT - Oversee and assign case loads and staff hours to best suit Hospitals needs
- COVERAGE - Organize case coverage during absence of staff
- PERFORMANCE - Assist in developing standards of performance, evaluation of performance, and initiates or makes recommendations for personnel actions
- LEADERSHIP - Provide leadership through identification of problems and opportunities for improvement, program planning, implementation, and evaluation
- 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
- RELATED WORK - Perform related duties and responsibilities as required
- ADMINISTRATION - Perform various administrative functions such as monitoring expenditures and preparing reports and correspondence; may participate in a variety of research projects to develop service plans; may propose changes to program policies and procedures
- DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
- STAFF - Assist in interviewing, hiring, orienting, training, coaching, evaluating, counseling, and supervising staff
- 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"