CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.
The Emergency Department (ED) Registered Nurse (RN) Case Manager provides the registered nurse component of the case management process, working collaboratively with the Social Work Case Manager and the Utilization Review team for assigned patients. The Case Management process encompasses communication and facilitates care along the continuum through effective resource coordination. The goals of case management include achievement of optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right to self-determination. The ED RN Case Manager serves in a gate keeper role to prevent inappropriate admissions from the ED and facilitates alternative transition options to match available resources to meet the patient’s clinical and psychosocial needs. The role typically focuses on ED and short stay observation patients, but also provides CM services to inpatient areas as needed and assigned.
1. Conducts clinical screenings to case identify potentially inappropriate admissions and at risk patients needing Case Management services, e.g. chronic diseases (such as heart failure, diabetes, COPD), frequent ED visits, frequent falls, need for long term IV antibiotics, enteral feedings, complex wound care, psychosocial issues, decline in functional status, and need for new high cost medications.
2. Conducts timely and comprehensive discharge planning assessments, as appropriate, for assigned patient populations according to department standards. Assesses current and anticipated clinical needs, current and anticipated living arrangements, functional status, patient’s ability to provide self-care, presence of a willing and able caregiver (if patient is not able to provide self-care), ongoing needs for medical equipment and/or an alternate care settings and/or services.
3. Facilitates transition/facility placement for patients on psychiatric holds once they have been medically cleared for discharge.
4. Maintains current knowledge of post-acute transition options (HHC, DME, SNF, behavioral health resources, etc.). Provides patient caregiver education regarding post-acute levels of care. Ensures informed decision making through explanation of choices, including in network providers and risks/benefits of choices. Promotes patient’s self-determination in all decisions. Integrates patient decisions/patient choice into the planning process by engaging the patient/caregiver.
5. Collaborates with patient/caregiver, physicians, case management staff and other interdisciplinary team members to determine patient’s post-discharge needs and plans.
6. Develops and executes transition plans applying appropriate population specific guidelines that allows the patient to discharge at the lowest level of restriction that provides a safe environment to meet continuing health needs. Communicates with and updates with all stakeholders regarding discharge plan/transition arrangements. Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/agencies adhering to patient privacy regulations and standards.
7. Identifies and facilitates resolution to medication issues which impact the discharge plan.
8. Proactively identifies barriers and intervenes to prevent operational bottlenecks that impede clinical progression and transition to the next level of care.
9. Makes appropriate state agency and community resource referrals, and works collaboratively to ensure appropriate consultation or further referral, as appropriate (e.g. APS, Area on Aging, Support groups, transportation, assistance with utilities, etc.).
10. Other duties as assigned by management.
Associates in Nursing
Registered Nurse in state of practice.
Minimum 3-5 years clinical experience as a registered nurse Demonstrated experience in case management, discharge planning, and transfer coordination. Must have excellent computer skills and ability to learn new systems. Knowledgeable regarding issues of chronic illnesses, loss/grief issues, change process, family systems, relationship principals, strength based interventions and community services. Must have strong organizational (time management) skills, strong interpersonal skills, the ability to handle multiple priorities with strong attention to detail. Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word. Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks).
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