Care Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the ESRC beneficiaries health and human service needs. It is facilitated through advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. This includes direct assistance in gaining access to services, coordination of episodes and transitions of care, chronic disease management, and linkages to appropriate services. Does not include direct delivery of medical, clinical, or other direct services. The overall goal of the position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration of case management, utilization review and management, care planning, and discharge planning for ESRD beneficiaries.
ASSESSMENT Completes required beneficiary assessments in a timely and thorough manner Daily monitoring of hospital admissions and discharges Regular contact with all hospitalized beneficiaries Assist beneficiaries to manage health issues, prevent decline and identify new risk factors Requests a rounding physician visit beneficiary within 7 days of a hospital discharge Identification and coordination of beneficiary co-morbid conditions
PLANNING Ensures bidirectional movement of beneficiary's PHI in a timely manner with other providers of health care Early identification and response to health care risks and symptoms to achieve long term positive outcomes and to avoid adverse and problematic events that lead to readmissions Organizes workload to complete responsibilities in a thorough and timely manner Works with other Care Managers in a collaborative manner, sharing outcomes, ideas, and activities Coordination of care for assigned patients, focusing first on high-risk beneficiaries associated with case load Ensures the hospitalized beneficiary's discharge planning is initiated within 24 hours of admission (unless a weekend admission) Utilizes beneficiary's PAM score to develop the plan of care when available Ensures the IDT meets for care planning weekly for four weeks after any unscheduled hospitalization
IMPLEMENTATION Builds alliances with other providers of care Works with MTM Pharmacist on medication reconciliation and management Schedules appointments with physicians, tests and other services confirming the beneficiary knows where to be, who to see, and has the means to get there Active engagement of beneficiaries, their family members and caregivers including education and support during and after hospital admission Ensures beneficiary's plan of care is communicated to all providers Coordinates the beneficiary's vascular access placement if has a catheter or placement of PD catheter if moving to peritoneal dialysis Implements the following programs for each beneficiary: "Start Smart," "Stay Smart," and, "Return Smart" Monitors and ensures the beneficiary's plan of care is implemented Acts as a health care 'navigator' for beneficiaries
EVALUATION Compares assessment data to baseline assessment to monitor beneficiary's progress with the appropriate changes to the Plan of Care. Demonstrates knowledge of therapeutic action, side effects and interaction of medications Monitors beneficiary's progress in meeting plan of care goals and works to modify the plan of care as the beneficiary's condition changes. Ensures results of all tests have timely and appropriate follow up
DOCUMENTATION Keeps beneficiary EMR updated at all times Completes and submits required reports in an accurate and timely manner to supervisor, unit QAPI team. Submits reports to each assigned unit's QAPI meetings on a monthly basis Keeps IDT updated in a thorough and timely manner
PERSONAL GROWTH Able to identify areas needed for growth Able to create a plan to develop knowledge, skill, and confidence in assigned work
EDUCATION, EXPERIENCE TRAINING AND LICENSES/REGISTRATIONS:
Registered Nurse (RN) currently licensed in the state of Ohio Bachelor of Science degree in Nursing preferred Case Management certification preferred Minimum of 5 years experience as a RN BCLS Demonstrated proficiency in MS Word, Excel, Power Point, and Internet use Flexible scheduling required Strong communication and organizational skills Autonomous in a team work environment Valid drivers license in the state of Ohio
The Centers for Dialysis Care (CDC) is an independent provider of dialysis and related health services to individuals with kidney failure. CDC is a growing organization that rapidly responds to changes, attracts and retains quality staff, and collaborates with physicians, providers, and payors.