Patient Assessment

1. Assesses all referred patients within the Prisma Health System to identify the need and appropriateness for Post Acute Services.

2. Communicates with patients, physicians, multidisciplinary care team and payors, the results of the physical, psychosocial, and financial assessment.

3. Assists Discharge Planners in formulating a plan in the best interest of the patient and family.

Planning

1. Works as a liaison with patient, family, multidisciplinary healthcare team and payor source to formulate placement plans. Goals and plans are updated and revised daily to reflect the patient's changing needs.

2. Attends discharge rounds to facilitate and make recommendations regarding the management of complex patients and to act as a resource regarding post acute care services.

3. Maintains open communication with Physicians, Nurses, Case Managers, Discharge Planners, Social Workers, patients and families concerning the patient's status and consideration for the next level of care. 20%

Implementation

1. Involves patient/family in plan for admission and in preparation for discharge from day of evaluation, taking into account the patient/family's cultural, ethnic, religious/spiritual beliefs.

2. Advises the discharge team in determining whether patient can be safely discharged back into the community setting.

3. Conducts preadmission physical assessment and rehab evaluation based on clinical appropriateness using PPS and RUGS to determine placement.

4. Identifies actual/potential delays in care provision, taking action as appropriate.

5. Integrates knowledge of payor requirements and federal/state regulations for placement along the continuum of care.

6. Works with family and financial counselors to determine if financial resources and services are being fully utilized and to make recommendations as appropriate.

7. Conducts patient/family education needed to facilitate the patient's move across the healthcare continuum as well as into the community.

8. Implements and follow guidelines established by regulatory and accrediting agencies. 25%

Program Tracking and Evaluation

1. Monitors and analyzes clinical and fiscal outcomes presenting data to management.

2. Collects clinical data for continuing evaluation of CMG's, and RUGS, in order to maintain compliance with governmental regulatory guidelines.

3. Participates in program evaluation, CQI studies and performance improvements for all Post Acute facilities.

4. Maintains database of referrals and admissions in order to report to team and accrediting/regulatory agencies if applicable.

5. On a quarterly basis, works in collaboration with other team members to perform program quality audits, identifying opportunities for improvement and making recommendations for implementation. 10%

Leadership

1. Acts as a resource for other staff by maintaining a strong clinical knowledge base in LTC, Sub acute, Inpatient rehabilitation, and Long Term Acute Care and utilizing critical thinking skills.

2. Provides information and acts as a resource for local, state, and national communities on specialty Rehab services through the GHS website and toll-free telephone number.

3. Participates in management groups, nursing committees, and quality improvement projects, demonstrating leadership in same.

4. Serves as a clinical resource to the interdisciplinary healthcare team.

5. Orients/trains new employees in all post-acute admission criteria and in department policies and procedures.

6. Actively seeks opportunities for continuing education to increase clinical knowledge and for personal development. 20%

Program Marketing and Network Development

1. Actively markets post acute services to hospitals, physicians within immediate and extended service areas.

2. Creates and delivers presentations on all post-acute services to physicians, case managers, social workers, etc.

3. Develops and maintains strong referral sources inside of the Greenville Health System. 10%