Case Management - RN

Internal Number : 11988

The Nurse Case Manager (NCM) is responsible for the coordination of care of individual patients in the Inpatient acute care environment at Nemours and those discharging from other community hospitals.

Through the use of the nursing process, the patient care will be assessed, planned, implemented and evaluated with consideration to the appropriate use of resources, anticipatory discharge and timely progression of care.

The NCM will manage care with a focus on designated clinical, operational, and financial outcomes for aggregate patient populations.

In collaboration with the interdisciplinary team and a family-centered process, the NCM will work to improve outcomes as measured by timely discharge from acute inpatient care, connection to post-discharge care / appointments, family / caregiver access to needed supplies, reduced readmission rates, and improved patient / family satisfaction.

Discharge planning, transitions of care and outpatient care of patients within the continuum of care will be aligned with :

Discharge planning, transitions of care and outpatient care of patients within the continuum of care will be aligned with :

• American Case Management Association Standards of Practice and Scope of Services (ACMA)
• American Case Management Association Transitions of Care (ACMA)
• Case Management Society of America Standards of Practice (CMSA)

The NCM is accountable for adherence to policies and procedures of Nemours Children's Hospital, Delaware, and other affiliated hospitals to which Nemours-delegated patients are admitted / seek care.

The NCM is expected to maintain all state and federal clearances for DE.

Essential Functions-

• Works with the Nemours Value Based Care Organization to ensure processes are in compliance with the standards established by current credentialing agencies.
• Screens patients seen in the acute inpatient care environment for gaps in care, opportunities for care coordination, and access to required supplies, DME, home nursing.
• Collaborates with providers, case managers, social workers and related care teams to understand care, treatment goals and overall plan of care.
• Uses clinical expertise and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes.
• Identify patients at risk for poor transitions, high Emergency Department utilization and / or readmission to hospital.

Will complete a comprehensive transition assessment and plan for on-going touchpoints for these patients. Will communicate needs and plan to providers, care team, outpatient care coordinators and, care managers, if referral is indicated.

Communicates and coordinates with the patient / family and the health care team to intervene when progression towards goals is stalled or diverted.

Addresses actual and potential barriers to achievement of patient care goals.

• Makes appropriate referrals to care coordinators and care managers
• If patient is enrolled in care management, ensure that established plan of care is dynamic and addresses all settings throughout the continuum of care.
• In tandem with case management teams and care coordinators, completes the interventions necessary for transitions to home with self / family care, home with services or short term skilled nursing facility placement.
• Makes appropriate referrals to home care, durable medical equipment (DME), and pharmacy vendors. Provides after visit summaries and other pertinent information related to on-going care in the home or placement.
• Works with other Nurse Case Managers to address short stay patients as needs relate to anticipatory discharge needs.

Qualifications-

Bachelor's Degree

RN licensure and BSN degree required

Case Management Certification : CCM, ACM-RN Preferred