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.
Leads and coordinates the patient/family evaluation and the formulation and implementation of a treatment plan. Collaborates with the physician and patient care associate caring for each patient in the evaluation and development of a treatment plan with input from other professions depending upon the presenting problem. Assumes primary responsibility for monitoring outcomes of collaborative interventions. Responds to the common issues raised by older persons with cognitive and physical impairments. Reviews the patient's problems while providing attention to the cost and burden upon the patient and family. Maintains a delicate balance between the patient's medical and nursing needs and the care needs of patients and families.
- 1. Interviews and assesses the family/caregivers and patient as part of a comprehensive geriatric assessment. Prepares psychosocial evaluation including psychosocial history, the history of cognitive and functional decline, a review of behavioral problems, ADL functioning, mental status and family stress/coping. This assessment requires knowledge of neuropsychology of aging; biology of aging and differential diagnoses of dementia. This assessment provides the basis for the diagnostic formulation. Develops the care plan in collaboration with the physician and rpatient care associate and assumes responsibility for monitoring the implementation of the plan by all disciplines. Addresses problems identified during the assessment.
- 2. All patient care responsibilities will be performed consistent with age-specific criteria.
- 3. Thoroughly and promptly documents the assessment and care plan. This documentation must provide concise and comprehensive information which communicates the assessment to a diverse audience of care providers.
- 4. Addresses the family/caregiver needs for education and support. Identifies and meets patient needs during the interview and subsequent telephone contacts and follow-up visits.
- 5. Monitors with the family the patient's responses to psychotropic medications and behavioral interventions and analyzes the family's abilities to follow through on the plan of care. Jointly with the physician, modifies the care plan based on the patient's response, new information and ongoing contacts with the patient and caregivers.
- 6. Is the primary person responsible for follow-up contacts with patients, families and other agencies/caregivers to ensure plan implementation and the maintenance of appropriate support. Communicates effectively and promptly, and engages other disciplines in resolving issues identified.
- 7. Provides independent caregiver consultations with families that do not require input from the physician or when direct patient contacts are not needed, desired, or possible.
- 8. Performs intake referrals and ensures that the following actions have been taken:
- 9. Identification of the problems prompting the referral for a geriatric assessment visit;
- 10. Establishment of initial rapport with the family;
- 11. Appropriate assignment of physician and case manager.
- 12. Collaborates with other professionals in developing a standardized database and measures that are used on all patients evaluated and cared for at the Adler Center.
- 13. Assists in the development and refinement of the Adler Center evaluation process.
- 14. Participates in writing grant proposals that enrich clinical practice and the expansion of services for older persons and their families.
- 15. Collaborates in the design and implementation of research projects in the Adler Center.
- 16. Participates in geriatric rounds and informal consultations with other disciplines to ensure the community and institution benefits from highly trained, experienced geriatric case managers working at the Adler Center.
- 17. Participates in and leads (when appropriate) educational programs offered to professional and lay caregiver groups pertaining to older persons.
- 18. Participates in and leads (when appropriate) Alzheimer's family caregiver educational programs offered in the community.
- 19. Participates in and leads (when appropriate) community boards to provide linkage to Yale-New Haven Hospital and the Adler Center and expertise to these groups.
- 20. Participates in and leads (when appropriate) programs to increase access for minority, indigent and other groups that do not fully utilize the Adler Center and other community services for older persons.
- 21. Teaches and mentors nursing and other students, geriatric fellows, residents and new geriatric providers participating in care at the Adler Center.
- 22. Participates in educational programs of the Department of Geriatrics at the Yale University School of Medicine and Yale-New Haven Hospital.
Master's degree in nursing required.
Clinical experience with geriatric patients and their families preferred.
Current/Valid CT RN license
Knowledge and experience in assessing, analyzing and formulating a complex clinical, social, financial and psychological issues as they pertain to older persons and their families. Knowledge of psychopharmacology preferred. Extensive decision making responsibility and the demonstrated ability to independently manage complex geriatric clinical care preferred. The case manager must be skilled in organizing and prioritizing data and information.
MSN required. Current CT RN license. 3-5 years experience in assessing, analyzing and formulating a complex clinical, social, financial and psychological plan for geriatric patients and families, Knowledge of psychopharmacology preferred. Extensive decision making responsibility and the demonstrated ability to independently manage complex geriatric clinical care. The case manager must be skilled in organizing and prioritizing data.