The RN Case Manager - Readmission Transition Coach is responsible for providing patients and caregivers with the necessary information and support during the transition from the hospital to home. Assists patients and caregivers with successfully managing their health care needs following a hospitalization. Facilitates care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
Utilization Management supporting medical necessity and denial prevention
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to physicians, patients, families and caregivers
This position leads a population of readmitted patients and or patients at an elevated or high risk for future readmissions, to escalate issues and trend/outline best practices for patients.
POSITION SPECIFIC RESPONSIBILITIES:
ï¿½ Identifies patients at high and moderate risk for readmission.
ï¿½ Runs daily readmission reports to identify patients that meet criteria for Transition Care Coach Program.
ï¿½ Meets with the patient at the bedside, explains the role of the Transition Care Coach and obtains consent. Engages the patient/caregiver to assess patient's preferences and goals before beginning the coaching relationship.
ï¿½ Teaches the patient/caregiver self-care techniques as appropriate. Utilizes teach back techniques. Communicates with the patient and family during the patient stay. Provides support and education to foster adherence to responsibilities agreed upon by the patient and family concerning care for the patient to remain healthy.
ï¿½ Works closely with RN's caring for the patient to coordinate delivery of instructions regarding: medications, diet, activity, signs and symptoms to watch for, and any other clinical instructions needed. Recognizes and utilizes opportunities for health counseling with patients and caregivers.
ï¿½ Provides telephone monitoring for 30 days post discharge from the hospital. Documents discussion and any actions or interventions after the call in hospital CM documentation system.
ï¿½ Completes accurate and relevant documentation.
ï¿½ Communicates and collaborates with physicians caring for the patient in the hospital and the primary care provider. Coordinates with assigned CM/SW to ensure patient care treatment instructions for home health care, skilled nursing facility and other health care team members are delivered (TOC) as needed.
ï¿½ Advocates for resources on the patient's behalf as appropriate.
ï¿½ Works in partnership with unit-based CM and SW to facilitate a safe and timely discharge to the next level of care.
ï¿½ Attends appropriate meetings and develops/provides presentations to educate health care team members about the role of the Transition Care Coach.
ï¿½ Participates in webinars, locates research/journal articles related to reducing readmissions and integrates current evidence-based research into Transition Care Coach model.
Continually evaluates the Transition Care Coach Program and offers opportunities for improvement.
Qualifications: Minimum Qualifications
1. Graduate from an accredited school of nursing. Bachelor's degree in Nursing or other health-related field, or equivalent combination of education and/or related experience.
2. Two years of acute hospital patient care experience. Acute hospital case management experience preferred.
3. License to practice as a Registered Nurse in the State of Michigan.
4. Accredited Case Manager (ACM) preferred.
5. Must complete Tenet's InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQualï¿½, Transition Management, Utilization Management, and other topics specific to case management.
1. Analytical ability, critical thinking, problem solving skills and comprehensive knowledge base to identify opportunities for improvement and problem resolution, evaluate patient status and health care procedures/techniques, and monitor quality of patient care.
2. Knowledge of care delivery capabilities along the continuum of care.
3. Interpersonal skills to work productively with all levels of hospital personnel.
4. Resourcefulness to identify prompt and sustainable solutions to barriers in care delivery.
5. Verbal and written communication skills to communicate effectively with diverse populations including physicians, colleagues, patients and families.
6. Teaching abilities to conduct educational programs for staff.
7. Flexibility with schedule, including off-shifts, weekends and holidays in order to meet the needs of patients, families or staff.
8. Organizational skills and ability to lead and coordinate activities of a diverse group of people in a fast paced environment, and direct others toward objectives that contribute to the success of the department.
9. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
10. Computer literacy to utilize case management systems.
Job: Case Management/Home Health
Primary Location: Detroit, Michigan
Facility: DMC Receiving Hospital
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905046942
About DMC Receiving Hospital
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.