SUMMARY:

Reporting to the Manager of Case Management, the nurse case manager is responsible for providing comprehensive screenings, assessment, care coordination services, disease education with the intent of encouraging self-management for patients with chronic conditions. The Nurse Case manager is integrated in the office-based healthcare team and thereby has face to face contact with identified high risk patients, frequent contact with primary care providers and medical home members to assist the patient to the right level of care and decrease unnecessary utilization. The nurse case manager is an active participant in the coordination and facilitation of interdisciplinary care team meetings and may be asked to organize a team meeting with all members of the care team. The nurse case manager collaborates closely with the primary care provider in order to identify those patients who may benefit from high risk case management (e.g. rising risk, frequent ED utilization). The NCM helps Brown Medicine achieve the triple aim of better outcomes, lower costs, and improved patient experience.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Based on the data presented, and ongoing collaboration with the provider, provides outreach and engagement in order to work with the most medically complex patients based on payer lists and Brown Medicine risk stratification algorithms.

Facilitates care transitions through timely outreach and communication of pertinent information necessary for patient self-management, readmission avoidance and coordination of services for those patients recently discharged from inpatient or skilled nursing facility. Coordinates, when necessary, resources within the practice and externally in order to ensure a safe discharge from the care setting.

Once stratified for complex case management, an initial assessment is completed including patient’s health status, clinical history, including medications, assessment of activities of daily living, assessment of behavioral health status including cognitive functions, life planning activities, evaluation of cultural, linguistic needs and preferences, evaluation of visual and hearing needs or limitations, evaluation of caregiver resources and involvement, evaluation of benefits and community resources as well as social determinants of health.

Based upon the initial assessment, creates and implements a individualized care plan with mutually set and prioritized goals and interventions. Review of progress towards goals are evaluated on an “as needed basis” and/or in order to meet set standards. Identification of social determinants and/or barriers are identified, and interventions developed in order to meet those needs. Utilizes motivational interviewing techniques to assist patients with establishing self-management goals and action plans with specified timeframes. The nurse case manager may facilitate referrals to resources. Timeframes for follow up on referrals are established to determine if the patient acted on these referrals.

The plan of care is shared with other care providers and with the patients/caregivers (in the language and their ability to understand) in order to coordinate care. The plan of care is a dynamic document and reflects the progress towards the interventions and meeting goals. It is modified any time a patient’s condition changes

The Nurse case manager has ongoing communication with the patient and provider to address patient/caregiver goals in order to effectively identify and gain understanding of appropriate level of care to provide.

The Nurse Case Manager may participate in end of life discussions with the provider and patient in order to support decisions related to palliative and hospice care when identified and deemed beneficial in order to support patient values regarding quality of life.

Maintains regular contact (face to face and/or non-face to face) with the patients and/or caregiver to educate, re-assess and support in a manner to foster patient/caregiver confidence, interest, participation and success.

Uses a multidisciplinary team approach as needed.

Documents in a timely manner and meets program requirements.

As a professional and key member of the healthcare delivery team, the NCM continuously updates his/her education and skills and participates in practice transformation activities. Maintains knowledge and skills in key disease states and syndromes.

Educates the team on care management and effective use of NCM services and competencies. Supports the overall quality programs and all staff operating at the highest level for their licensure or scope of duties.

On a limited basis, the NCM applies their skills for short term intervention on patients who are not established as high risk, nor need a comprehensive care plan, but may be experiencing an exacerbation of their condition, and/or identified as “rising risk” and would benefit from NCM interventions followed by routine surveillance in the future.

Meets contractual, accreditation and regulatory standards and requirements.

Consistently applies the Brown Medicine values of patient care priority, dignity, collaboration, integrity and quality in support of the UMF mission to deliver compassionate, high-quality patient care, research excellence and outstanding physician education. Is responsible for knowing and acting in accordance with the UMF Compliance Program and Code of Conduct.

Consistently practices the Brown Medicine Physician Group Customer Service Standards.

KNOWLEDGE, SKILLS & ABILITIES REQUIRED:

Nursing knowledge for adults cared for in an ambulatory setting, including the skills to comprehensively assess patients. Familiarity with behavioral health and palliative care is necessary.

Ability to perform in a metric driven environment in order to meet program and quality metrics.

A knowledge of care management, community resources and documentation and communication tools.

Highly organized, detailed and ability to work with general direction using sound judgment and decision-making.

Effective written and verbal communications.

Able to work with patients and caregivers to address difficult issues and able to work with members of the patient’s entire care team to promote patient-centered, comprehensive, coordinated care.

Ability to motivate others.

Adaptability to a changing healthcare environment and delivery system.

Possesses or learns essential computer skills (eg electronic health records, word processing, spread sheets).

EDUCATION AND EXPERIENCE:

Degree in Nursing from an accredited school.

Three (3) to five (5) years of experience in community health setting, public health, chronic disease management, community nursing, case management preferred.

Experience working with primary care providers to coordinate care and disease management.

Experience working with patients regarding their care coordination and condition(s) is preferred.

Certification in disease management and/or case management preferred.