Evaluation and Outcomes

Evaluate the timeliness and availability of treatments and services, and adjusting level of service according to changing needs. Evaluate actual patient outcomes in relation to expected outcomes for the care managed population. Identifies quality improvement opportunities such as consistent issues with smooth care progression and communicates them to the department's management/leadership team, providing supporting data and reference to evidence based practice when possible. Participates in the management of metrics (outcomes, value, and experience) across the continuum of care.

Monitoring

Monitor the patient's progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames. Utilizes Critical Pathways and /or Clinical Guidelines to monitor patient progress toward health. Follows through on the status of key diagnostic and treatment tests and procedures to insure continued progression. Interacts with involved departments and other members of the healthcare team to negotiate and expedite scheduling and completion of tests and procedures. Identifies, documents and communicates barriers to the plan of care to the healthcare team. Serves as the contact person for and works collaboratively with the multidisciplinary team to manage resource usage/utilization.

Coordination

Facilitates communication and coordination between members of the health care team across all phases of care. Involves the patient, family and caregivers in the decision-making process in order to minimize fragmentation in services. Leads the coordination of care, setting priorities and encouraging the appropriate use and timeliness of health care services Facilitates a smooth transition of care by insuring that key components of the plan of care and/or patient needs are communicated, to subsequent care providers across the continuum. Demonstrates an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, CMS, legal P&P) impacting the care delivery and reimbursement process. Negotiates and advocates for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources, or other needs as identified. Creates an environment to support patient safety by integrating patient safety goals into daily practice based on the patient's age and the population served.

Planning

Planning with the patient, family or caregiver and providers, to maximize health outcomes and ensure quality, cost effective care. Works with the patient, family and caregiver, to establish treatment goals that meet the patient's healthcare and safety needs. Integrates patient, family and caregiver decisions and choice into the planning process. Coordinates the plan of care and maintains documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identifies the need for patient/family team meeting, participates in the meeting and documents the outcomes. Proactively identifies medical and psychosocial services needed by the patient. Reassess plan of care and adjusts plan according to patient needs.

Implementation

Implementing the agreed upon plan of care. Provides self-management support to high risk/complex patients and families, including helping families identify and overcome barriers to care. Utilizes collaborative communication skills to establish a working partnership with the patient/family/caregiver, treatment team, and community resources/providers. Educates the patient, family and caregiver along with members of the health care delivery team about treatment options. Empowers the patient, family, and caregiver to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Encourages the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case by case basis. Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care.