RN Care Manager - Case Coordination

Location Detail : Charlotte Hungerford Hospital (10115)

Shift Detail : Monday - Friday 8am - 4 : 30pm with rotating weekends

Work Location Type : In Person

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Charlotte Hungerford Hospital is a 122-bed, general acute care community hospital located in Torrington, Connecticut, that serves as a regional health care resource for the 100,000 residents of Litchfield County and Northwest Connecticut.   CHH offers personalized attention from an expert team of caregivers and physicians that utilize advanced technology and clinical partnerships in a convenient, safe and comfortable patient environment.

POSITION SUMMARY / PURPOSE

Care Management is a collaborative practice model including patients, nurses, social workers, physicians, healthcare team members,, caregivers and the community.  The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination.  The goals of the Care Management Team include the achievement of optimal health, access to care and appropriate utilization of resources balanced with the patient’s right to self-determination.

Incumbents of this position are professional Registered Nurses that utilize the nursing process (assessment, planning, intervention, documentation, and evaluation) to determine and facilitate the most appropriate level of care and identification of discharge needs. Collaborates with physician to ascertain medical treatment plan and with nursing, other health care team members and health plans to fulfill the treatment plan in the highest quality, cost effective manner.  Responsible for ensuring customer satisfaction (patient, family, physician, others), maintaining patient confidentiality and being sensitive to the age and cultural specific patient needs for comfort, privacy and generalized care.  .

ESSENTIAL FUNCTIONS

• Displays and upholds CHH core values of dignity, compassion, service excellence, community and integrity.  Consistently demonstrates caring for patients, for one another, and for the organization they are part of, and contributes to building trust, pride and camaraderie and collaboration with the Health Care Team.

Incumbents of this position will strive to gain the respect and maintain the dignity of patients / family members, visitors and all Charlotte Hungerford Hospital Personnel. Demonstrates a diplomatic and supportive attitude and presents the hospital in a positive manner to all persons above.  Promotes and contributes, in a positive manner, to inter- and intra-departmental relationships to ensure all needs of the patient are met.  Maintains confidentiality of all appropriate information and documentation.

Responsible for complete and thorough patient and family assessments for initial and on-going care and discharge planning, addressing physical, psychosocial, religious, cultural and educational aspects. Identifies and communicates appropriate information gathered from patient, family, chart, community agencies and colleagues to other members of the multidisciplinary health care team.  Actively coordinates patient care including the sequencing and scheduling of tests, procedures, and consultations. Works closely with physicians to coordinate hospital services from pre-hospital through post discharge recovery.

Ensures patient and family understand the diagnosis and planned course of treatment and determines and communicates discharge needs.  Identifies gaps / barriers to care and facilitates interdepartmental communications to expedite appropriate changes. Additionally, incumbents are responsible for assessing any financial needs of the patient / family, including assisting in the clarification of benefit plans.

Assists Social Worker Care Managers with highly clinical complex patient needs.

Responds expeditiously to emergency needs of patient and families in crisis by providing appropriate interventions necessary to support and stabilize.

In conjunction with patient, family, payers and other members of the health care team : formulates and implements a discharge plan to address assessed needs and patient / family concerns,; evaluates the effectiveness of the plan in meeting the established care goals; and revises the plan as needed to achieve desired outcomes.

Refers patients to a variety of resources including, but not limited to, Visiting Nurse Agency, Skilled Nursing facility, Long Term Care Hospital, Rehab Facility, Hospice Care, Durable Medical and Respiratory Care providers.

Assures Follow-up care with Providers has been arranged with confirmation of the  patient’s ability to access the scheduled appointment..

Telephone Contact to patient’s who are at a high risk for readmission within 48 hours of discharge to verify the follow-up services has occurred as planned;  Patient and Family understand and are following their discharge instructions and Patient and family are able to follow-up with their provider for evaluation.

Pro-actively advocates for patient care issues to ensure that overall quality and type of care is sensitive to each specific patient / family’s needs

Analyzes patient care trends and actively seeks out and collaborates with the care team to improve overall quality and efficiency of care

Seeks out and / or provides peer consultation about cases that are presenting problems and or experiencing significant deviations from the plan of care. Attends and participates in extended stay rounds, daily outcome planning rounds, Case Management Team meetings and peer reviews regarding management of their caseload.

Participates in quality improvement and evaluation processes related to the Care Management function. Abstracts data from the medical record to enable the review of selected hospital core measures or for review by external agencies such as the JCAHO, CMS and / or QIO. Collects and trends a variety of data to identify avoidable hospital days and / or process improvement opportunities.

Meet required job specific competencies for assigned unit, including mandatory educational requirements.  Maintains professional growth and development through seminars, workshops and professional affiliations to stay current on the latest trends related to position.  Participates in staff meetings, educational programs and in-service meetings to maintain competencies. Complies with hospital policies and procedures related to safety, infection control, attendance, sexual harassment, dress code, corporate compliance, confidentiality and others.  Communicates to Administrative Director and / or Management staff needs identified for self, the unit and other team members.

JOB KNOWLEDGE, SKILL REQUIREMENT AND REQUIRED ATTRIBUTES

Qualifications

EDUCATION

EXPERIENCE

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With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth.  Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children.  We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure work / life balance.  Every moment matters.  And this is your moment.