Overview

The Care Manager- Discharge Planner is a core member of the hospital care team and leads discharge planning through full partnerships with caregivers, internal and external providers/customers, and patients and their families and communities. This role contributes to the transformation of the health care system into one that meets the demands for safety, quality, patient-centered and affordable care. This position is responsible and accountable for coordinating the interdisciplinary process that occurs throughout the continuum of care to ensure care coordination, communication and collaboration with patients, families, providers, ancillary services and community partners in order to achieve goals and maximize positive patient outcomes based upon individual assessments of patients' needs. Discharge planning will begin at the time of (and prior) admission, and reassessed during hospitalization. Concurrently intervenes to enhance patient quality outcomes and serves as a patient advocate.

Responsibilities

Discharge Planning

• Leads the discharge planning process which links the patient-family with the appropriate institutional or community resources post discharge and starts at time of admission or prior to planned hospitalization or surgeries.
• Utilizes Key Elements for Evidenced -Based Discharge Planning:
• Include Patient and Family as full partners in the Discharge process
• Discuss with Patients and family the five key areas to prevent problems at homes
  • Describes what life at home will be like after discharge
  • Review medications
  • High light warning signs and problems
  • Explain the plan of care including test results
  • Make follow- up appointments
• Educate patient and family using plain language about the patient’s condition, the discharge process and next steps in the patients care plan.
• Assess how well doctors and nurses explain: diagnosis, condition, and next steps in the patients care to the patents and family using teach back strategies.
• Listens to and honors the patients and families goals, preferences observations and concerns.

Supports the Care Management/Utilization Review Roles and Functions

• Case Management: Serve as a clinical resource. Contribute clinical knowledge and expertise to facilitate the attainment of the agreed upon goals of care.

• Collaborate with insurance companies, Social work, and other hospital departments when patient care needs exceed health benefit coverage limitations to negotiate and provide for patient care needs.

• Patients will be assessed to determine appropriateness of admission, use of observation status, continued hospitalization. and placed in appropriate level of care. Maintain knowledge of Medicare-Medicaid guidelines and coding specifics. Communicate with physicians to ensure compliance with Guidelines.

• Communicate with third party payers and insurance companies. Provide clinical information, including patient status, plan of care and discharge disposition as requested.

• Utilizes MCG, Intensity of Service, and Severity of Illness criteria to determine eligibility for acute care and observation services.

• Utilization Review: Perform both concurrent and retrospective monitoring and analysis of variations in the processes of care. Identify and recommend opportunities for improvement as appropriate. Collaborate with nursing/MD, Quality Improvement department.

Qualifications

Education:

• Associates Degree in Nursing

Experience:

• Minimum of three (3) years relevant clinical experience including demonstrated use of discharge planning, utilization, and quality management skills. Chart reviewing-auditing, and able to extract and analyze data.

License and Certification Requirements:

• RN License in Vermont in good standing

Skill Requirements:

• Strong clinical skills, leadership, and computer skills.
• Able to establish and maintain strong working relationships.
• Self-directed, assertive problem-solving.
• Effect assessment and planning skills.
• Effective written and oral communication skills.
• Champions and builds interdisciplinary teams.