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• Baltimore, MD
• SINAI HOSPITAL
• CARE MANAGEMENT
• Part-time w/Weekend Commitment - Day shift - 8:00am-4:30pm
• RN Other
• 85295
• Posted: September 11, 2024

Summary

• Assessment: Performs initial and ongoing Care Management assessment to determine, based on patient's condition and presentation, care coordination and discharge planning needs as appropriate in the Inpatient setting.
  • Tasks: Reviews all cases within 12-24 hours of admission from all points of entry and each day throughout the stay to facilitate care coordination and discharge planning needs including social work intervention. Initiates post discharge link with external care sources i.e. Transitional Care Coach. Defines a working length of stay based on admission diagnosis. Conducts concurrent daily medical record review to measure patient progress against anticipated for discharge, level of care, and length of stay. Confirms appropriateness of level of care status. Assimilates information obtained from emergency department visit, information systems, ancillary/diagnostic test results, registration area, bed management, clinics, and other facilities to accurately assess patient clinical needs and treatment. Confirms completion of high risk for readmission screening tool for patient assignment to the Care Transitions Program. Confirms communication to Care Transitions Coach has been performed per organizational policy/practice.

• Planning: Creates a focused, anticipated discharge plan of care for assessed high risk patients with identified needs.
  • Tasks: Creates and coordinates the overall transitional and discharge plan of care based on initial assessment in collaboration with social workers, direct care providers, other hospital departments, Care Transitions Coach (where appropriate), external service organizations, agencies and healthcare facilities, and the patient and family. Expedites proper sequencing and scheduling of interventions, treatments and procedures in accordance with the patient’s treatment plan and during inpatient and transition phases. Initiates Discharge Checklist/planning. Reviews in-hospital and transitional plan of care and anticipated discharge date with Care Transitions Coach when appropriate. Plans for Pharmacy consultation prior to hospital discharge for any high-risk for readmission patient with five or more medications or as clinically indicated. Confirms appointment with Primary Care Physician has been scheduled.
• Intervention/Evaluation: Collaborates with the clinical team and medical provider to initiate the anticipated discharge plan for patients.
  • Tasks: Facilitates communication within the healthcare team to coordinate the patient’s anticipated discharge plan of care. Acts as patient advocate by negotiating for, and coordinating resources with LifeBridge Health, payer, agency and vendor systems to expedite care and avoid care delays and denials of payment. Coordinates and facilitates multidisciplinary rounds according to accepted practice/policy with a focus on the achievement of clinical/discharge milestones and confirmation of the completion of patient education as appropriate. Escalates cases, as appropriate, to Physician Advisor when unable to progress patient along defined plan of care. Collaborates with physician, nursing, patient access/bed management, etc. to ensure appropriate admission to/from all access points based on level of care. Assures/Confirms that linkages to pre /post-hospital services are in place. Documents avoidable days, lower care rate, care manager assessments, expedited appeals and plans of care in a thorough and timely manner, and per department policy, in appropriate system. Encourages appropriate care provider documentation to reflect patient’s anticipated discharge plan of care as appropriate.

Qualifications/Requirements: 

• BSN preferred; ADN required
• 3-5 years related experience 
• Maryland Registered Nurse License/Intent to achieve MD licensure if out of state
• Case Mgmt cert preferred 3-5 yrs of hire for role

Additional Information