To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Transitional Care Manager is responsible and accountable for ensuring high quality patient care that is coordinated, efficient and supports desired clinical and financial outcomes. In collaboration with the healthcare team, the Transitional Care Manager utilizes evidence based practice to ensure that specific patient outcomes are achieved and that resources are appropriately used within designated fiscal time frames. The Transitional Care Manager participates in the ongoing evaluation of care delivery systems and practice patterns through identification of barriers to all aspects of care, including clinical, financial and community.
Responsibilities: 1. As part of the interdisciplinary health care team, coordinates and ensures the implementation of the plan of care, utilizing the principles of case management. 1.1. Establishes a system for coordinating the care of a patient throughout the continuum of care, linking the inpatient care with outpatient care, services and case management. 1.2. Risk assessment & stratification (using modified BOOST, Rothman index and other readmission reduction tools) 1.3. Medication Reconciliation verification 1.4. Directed patient education about disease, medications and management 1.5. Alert Inpatient teams of high-risk patients (incorporate into Transitional Care Rounds) 1.6. Ensure ongoing management with patient's current medical home / ambulatory care and management team (i.e. NEMG PCMH, CHN Intensive Care Managers, etc.) 1.7. Follow up phone calls to patients/community providers
For bundled patients calls are made at 24-48 hours, 10- 12 days, 30,60 and 90 days. 2. Ensures that an appropriate discharge plan is developed and implemented with the health care teams members to include: 2.1. Utilizing knowledge of internal and external resources to meet patient needs; 2.2. Identifying barriers to wellness within the treatment plan. 2.3. Facilitation of referral/actions to identified barriers. 2.4. Ensuring and/or coordinating counseling, teaching referrals for transitions of care. 2.5. Updates care management plan to reflect actions. 3. Facilitates movement along the continuum for patients within identified parameters 3.1. Ensure that the appropriate outside agencies are contacted and necessary referrals are initiated and followed through. 3.2. Links patient and family with the appropriate institutional or community resources, advocate on their behalf for scarce resources, and developing new resources where gap exist in the service continuum. 3.3. Communicates updates with PCP and documents. 4. Along with other members of the health care team, acts as a patient advocate. 4.1. Exhibits awareness of ethical/legal issues concerning patient care and strives to manage situations to reduce risk. 4.2. Educates patients and families regarding the transitional care manager role, as needed. 4.3. Facilitates and ensures open communication among the health care team and the patient/family. 4.4. Performs miscellaneous duties as required or requested.
Minimum of a Baccalaureate degree in clinically related field. R.N. required.
Minimum of five (5) years of relevant clinical experience.
RN Licensure in Connecticut
Case Management experience a plus. Motivational interviewing skills necessary.
Knowledge of discharge planning services and familiarity with utilization review practices. Excellent verbal and written communication skills. Excellent interpersonal communication skills with interdisciplinary team. Possesses excellent organizational skills and ability to handle multiple priorities. Ability to learn multiple computer systems. Ability to act in an independent role with minimal supervision. Flexible working together in a team and sharing responsibilities.
Accountability will be measured by regular reports of number of patients enrolled, interventions documented, readmission rates, and feedback from managers, other staff, and patients/families.
Requires in-depth understanding of insurance and reimbursement systems. Requires independent problem-solving skills in coordinating care across the continuum and within the health care system (calling physicians, home health agencies nurses, social work). Must embody principles of High Reliability-including communicating effectively with peers and arcing up concerns, accountability, mentorship and practicing and accepting a questioning attitude.