1. Assess the physical, functional, social, psychological, environmental, learning and financial needs of patients.
2. Identify problems, goals and interventions designed to meet patient's needs, including prioritized goals that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
3. Assist with creation of IP care plan including objectives, goals and actions designed to meet patient's needs.
4. Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
5. Assess the patient's formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources.
6. Implement and monitor the IP care plan to ensure the effectiveness and appropriateness of services. Maintain ongoing communication with UR Nurse regarding same.
7. Evaluate patient's progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status.
8. Research alternative treatment options and selecting and locating appropriate providers which can include facilitation of referrals.
9. Communicates with attending and primary care physician and members of the comprehensive care team regarding status of patient.
10. Utilize motivational interviewing skills to build patient engagement in case management plan of care.
11. Provide education, information, direction and support related to care goals of patients.
12. Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
13. Coordinate care and develop treatment plans.
14. Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved. coordinate discharge services to avoid duplication.
15. Maintain accurate patient records and patient confidentiality.
16. Measure outcomes and effectiveness of case management including clinical, financial, quality of life and patient/family satisfaction.
17. Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.
18. Facilitate disease prevention and health promotion with patients and families
19. Determine psychosocial needs & complex medical needs of all patients
20. Troubleshoots problems regarding operational and clinical procedures that may affect patient outcomes.
21. Attend mandatory training sessions and staff meetings as assigned.
22. Participate in prospective, concurrent, and retrospective case reviews involving targeted patients.
23. Identify risk factors and teach patients clear pathway of response to identified triggers
24. Promote patient and family responsibility and self-management
25. Document all relevant information following department policy guidelines.
26. Maintain knowledge of operational procedures and case management program components.
27. Promote chronic disease management concepts, health screening and preventive health initiatives for targeted patients
28. Participate and promote appropriate performance improvement projects Program Development:
29.Assist with the collection, analysis, and benchmarking of utilization data.
30. Collaborate in the development of protocols and guidelines for patient care management.
31. Adhere and uphold Beebe Healthcare's Mission, Vision and Values and Performance Standards
32. Other tasks as assigned