Transitional Care Manager

MISSION STATEMENT
The mission of The University of Texas M. D. Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.

SUMMARY

The primary purpose of the Transitional Care Manager on MD Anderson’s new Transitional Support Team is to engage with patients, families and caregivers prior to hospital discharge to develop a partnership with the patient to manage care after hospital discharge and reduce probability of readmission. The role will proactively identify patients with unmet care or social needs and provide proactive assistance in navigating the patient’s transition from hospital to home, hospice or post-acute settings through education, coaching, telephone outreach, and discharge preparation including but not limited to medication management, communication with primary care, and symptom management. Transitional Care Managers will serve as a primary point of contact for assigned patients and will be responsible for early identification of symptom exacerbation, coordination of appropriate interventions and addressing unmet needs to prevent avoidable hospital admissions. Patient care will be provided telephonically and as needed, in person during admission or emergency department encounters. The Transitional Care Manager will also be responsible for communicating with assigned patients who present in the Acute Care Cancer Center or Urgent Symptom Clinic to assist ambulatory care teams in evaluating patient’s needs, counseling patients around goals of care and supporting ambulatory teams in meeting patient needs at the lowest possible level of care.

JOB SPECIFIC COMPETENCIES

Care Coordination (70%)

·         Serve as a primary point of contact for assigned patients prior to hospital discharge and post hospital discharge, ensuring continuity of care

·         Identify and mitigate factors contributing to readmissions, working proactively collaborate with interdisciplinary teams to develop and implement individualized post-discharge care plans.

·         Address the patient’s unique needs including but not limited to patient/caregiver education, medication adherence, and follow-up care in post-discharge care plan.

·         Develop trusting relationships with both patient and caregiver.

·         Educate patients and their families about post-discharge care and options for care to address any urgent/emergent issues post-discharge.

·         Provide ongoing patient/caregiver coaching as needed.

·         Conduct regular follow-ups to monitor patient progress, address any emerging issues, and ensure continuity of care; Identify potential complications and intervene promptly.

·         Provide education on advance care planning and complete documents. Ensure patient and family comfort with plans of care and address questions/concerns as needed.

·         Provide education on hospice and facilitate goals of care conversations between patients and their cancer team.

·         Maintain seamless communication with both cancer care team and primary care doctor regarding changes in patient’s clinical status and goals of treatment.

·         Connect patients with relevant community resources to support their post-discharge needs and address unmet Social Determinants of Health factors that may contribute to poor outcomes (prescription access, transportation, food, housing, etc.).

·         Provide timely and accurate response to patient inquiries via telephone, email, or myChart messaging; Connect patients with institutional resources where appropriate.

·         Provide patients with all appropriate materials needed for post-discharge care.

·         Document post-discharge care plan and other relevant documentation in the electronic medical record and other required reporting platforms

·         Work collaboratively with Case Management Navigators, AskMDAnderson, Patient Navigators and clinical teams in the inpatient and outpatient setting to successfully assess and address patient needs.

·         Partner with key external stakeholders (home health, hospice, etc.) to ensure patient needs are met post-discharge.

Knowledge Management & Team Partnership (10%)

·         Demonstrate understanding of patient needs and clinical/operational best practices.

·         Maintain and apply clinical and institutional knowledge to render best possible post-discharge support to patients/caregivers.

·         Demonstrate competency in job related tools such as MS Office (Outlook, PowerPoint, Word), OneConnect (Epic), Zoom/Teams, and telephone system.

·         Proactively obtain and integrate relevant training, ongoing education, professional development, and certifications for the role and maintain nursing license.

·         Serve as contributing participant of assigned project teams.

·         Contribute to creative problem-solving, evaluate progress and identify and/or report obstacles/barriers.

·         Utilize available data to identify trends related to high-risk readmissions, develop interventions and continuous improvement strategies.

·         Follow established care management clinical workflows and documentation requirements.

Customer Satisfaction (10%)

·         Perform quality control review of communications, materials, and customer feedback to continuously refine quality of service provided.

·         Provide empathetic, emotionally intelligent support to patients and colleagues through active listening, just culture problem solving, and timely responses.

·         Employ High Reliability principles to decrease avoidable readmissions and prevent potential patient events.

Other duties (10%)  as assigned.