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To facilitate and manage care coordination and case management across the continuum of care for UC Health patients. Working within a collaborative framework, insures the effective and efficient coordination and management of care to all patients within his/her caseload. This individual works to ensure that patients move along the health care continuum, promoting quality care, through appropriate, cost- effective interventions while maintaining close contact with patients, families, care providers, payers and community resources.
PATIENT POPULATION - (CLINICAL ONLY) Engages in population appropriate communication. Has knowledge of growth and development milestones and tasks. Gives clear instructions to patients/family regarding treatment. Involves family/guardian in the assessment, initial treatment and continuing care of the patient. Identifies any physical limitations of the patient and deploys intervention when necessary. Recognizes and responds appropriately to patients/families with behavioral health problems. Interprets population related data and plans care appropriately. Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely. Recognizes and responds to signs/symptoms of abuse or neglect. Compliance Patient Services Staff - Sustain an understanding of regulatory requirements and accreditation standards. Supports leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Monitor safety and departmental policies and procedures. Ensure all employee certifications and UCH training along with yearly training requirements are fulfilled in a timely basis. Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices. Comply with all of UC Health's processes and freely communicate safety and compliance concerns to leadership. Interprofessional Practice: - Demonstrate consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice. Patient Care - Possess knowledge of Age Specific and Culturally Diverse human growth and development Consistently integrate age specific and culturally diverse concepts into patient care, taking into consideration both the patients' chronological age and developmental functioning. Assessment - Conduct a comprehensive assessment of health and psychosocial (Social Determinants of Health) needs. Identify cases that meet criteria for case management (Comprehensive needs assessment). Meet each new patient within the caseload to introduce self and explains the Case Manager Role. Identify the patient's support system and financial situation and initiate referral to Social Work as needed. Planning - Plan with the client, family or caregiver and the provider to document a patient centered plan of care focused on achieving quality, and cost effective outcomes. Work with the patient/family, establish self-management goals that meet the patients' healthcare and safety needs. Integrate patient/family decisions and choice into the planning process. Coordinate the plans of care and maintain documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identify the need for patient/family team meeting, participate in the meeting and documents the outcomes. Proactively identify opportunities for coordination and efficient care and advocates on the behalf of the patient to achieve the best outcome possible. In collaboration with the provider (s) reassess plan of care and adjusts plan according