The RN Transitional Care Case Manager is responsible for managing a patient's successful transition from hospital to home and is accountable for developing, implementing and evaluating comprehensive transitional care interventions for high risk medical and/or surgical patients. He/she is responsible for managing the post-acute care of high risk patients that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions and working with complex and varied patients and situations. The RN Transitional Care Case Manager identifies hospitalized high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize care coordination.
Upon patient hospital discharge, the post-discharge workflow is telephonic follow-up for 30 days facilitating clinical care, patients' access to appropriate services and service referrals and appointments. This according to protocol, includes a focus on medication reconciliation and adherence, management of both acute and chronic disease states, identification and rectifying gaps in care, assessment and support of patient's ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health) and coordination of care across the care continuum.
The RN Transitional Care Case Manager utilizes research findings in practice and participates in the Transitional Care Management program design, implementation and evaluation. They will participate in ongoing quality improvement activities and collect clinical path variance data indicating potential areas for system wide improvement. The Transitional Care Case Manager will help the primary care providers identify errors and discrepancies in care that negatively impact the patient. They will then help to rectify those through a broader system approach which may include, contacting individual discharging providers, attending physicians and resident physicians, to provide feedback on gaps in care.
Education, Work Experience and Licensure: