Overview

The Care Manger position is an integral part of the healthcare team working closely coordinating inpatient and outpatient care and services across the continuum of care assuring and including Primary care and Specialty providers. The Care Manager utilizes his/her skills to coordinate internal and external resources to facilitate appropriate resource management of an age specific patient population which spans from newborns to geriatrics, identifying opportunities for process improvement, high risk cases and sentinel events, to the achievement of an acceptable outcome. The Care Manager’s role in data collection, analysis and summarization supports performance improvement/quality programs, risk management, clinical pathway development and outcome measurement using guidelines. They possess the ability to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective, dynamic professional team relationships. This position is an integral part of the Patient Centered Care team. The Care manager works under the supervision of the Regional Director- Patent Centered Care Management to support the objectives of UVM Health Network - CVPH and the Medical Home. Responsible to identify at-risk patients and develop plan of care based on risk and patient goals to meet individual health needs through communication and assisting with access to resources to promote quality, cost-effective outcomes across the continuum of care.

Position Insights:

• This is a regular part-time, 56-72 hours per pay period position
• Salary Range: $32.14/hour-$47.57/hour
• $10,000 Sign-On Bonus for 1 Year Committment (pro-rated for part-time)

Responsibilities

• Customize care of each patient, ensuring that it’s culturally and literacy level appropriate.
• Understand patient preferences and optimize care as circumstances change.
• Assess, plan, coordinate and evaluate at-risk patients to promote healthy living with emphasis on prevention, self- management and behavioral changes to reduce hospital admissions and utilization of emergency department.

• Utilize a multidisciplinary approach for the patient’s care to promote a heightened focus on the patient needs/preferences.
• Identify and implement a Patient centered multidisciplinary care plan.
• Gather information necessary to accurately assess and address patient needs and work with multidisciplinary team to develop and monitor individualized patient centered plan of care based on risk and patient goals.
• Promote dialogue between patients and providers helping to guide them through the continuum of services and assist with transition from hospital to home/alternate level of care settings.
• Support patients to better self-manage chronic conditions to include: interact with pharmacist related to medications when required; identification of barriers, behaviors, etc. to promote healthy living.
• Provide education to patients and their families about care plan, importance of follow-up with providers, risk factors, monitoring of symptoms, medication management and available resources.
• Coordinate resources and referrals as identified.
• Establish and maintain effective working relationships with health care providers.

• Understanding, educating and communicates to the patient the importance of Patient Centered care.
• Integral role that patients participate in creation of their plans of care in their overall health

and wellbeing.

- Patients participation, in easy-to-understand terms creating there to overall plan of care.

• Tailor communication to reflect patients’ needs IE: open ended questions to gain insight into the patient concerns or preferences required.
• Provide, during the process, options of care. Shared decision allows the patient values and preferences first, discussing the pros and cons of treatment options.
• Offer educational material, so patients can choose appropriate treatments to facilitate autonomy, self-care and health promotion.

• Ensure that the patient is physically comfortable to promote and be actively engaged in patient-centered care as it relates to the following;
• Pain management
• Assistance with activities of daily living
• Familiar with hospital surroundings and their environment.

• Evaluate anxiety associated with illness which decreases wellbeing
• Understand how this illness intervenes their overall wellness and family.
• Evaluate anxiety regarding the financial impact of their illness.

• Provide accommodations for family and friends.
• Involve family and close friends in the decision making process.
• Support family and friends as the caregivers to this patient.

• Evaluate and provide opportunities for patient to express concerns about their ability to care for themselves after discharge.
• Obtain, but not limited to, insurance authorization for discharge needs.
• Provide information regarding medication, physical limitations, dietary needs, DME, etc.
• Provide a coordinated approach to the continuum of care with outside services once discharged; IE: Home Care Agency, Rehab services, Transitions of Care, Specialty/PCP, etc.
• Refers patients appropriately for Adult homes, Sub Acute, Nursing facilities, Acute Rehab and Hospice as appropriate, etc. Completing PRI if required for these facilities
• Provide information related to anticipated services and the associated cost of those services.

• Provide information related to access to care once they are discharge.
• Work with community based organizations, Primary Care physician’s offices, Specialty physician offices, etc., to assure a seamless continuum of care.
• Assure that appointments at discharge are scheduled for the patient prior to discharge.
• Coordinate and assist in following through with Primary care and specialty appointments.
• Work with the patient/family and other agencies to assure transportation to appointments is available post discharge.
• Promote healthy lifestyles and improved services throughout the communities served by the Medical Home. Duties include but are not limited to:
• Provide education to promote healthy lifestyles across populations in the community
• Provide care management supports to patients identified as high risk by the practitioner or meeting criteria for Health Home eligibility to ensuring patients are connected and utilizing community resources for self- management of their disease states.

Other duties as assigned.

Qualifications

As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.