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Registered Nurse Case Coordinator
2 months ago
Job Overview:
The Registered Nurse Case Coordinator plays a crucial role in overseeing patient progress and ensuring a seamless transition plan that is both safe and sustainable.
This position involves collaboration with Physicians and the Interdisciplinary Team to establish a comprehensive plan of care, treatment protocols, estimated length of stay (LOS), and potential discharge options (home, LTAC, SNF, or ALF).
It is essential to ensure that the Physician and Interdisciplinary Team communicate the estimated LOS, tentative discharge date, and assessed discharge needs with the patient and their family.
A thorough review of the medical record is necessary to anticipate clinical stability and gain a comprehensive understanding of the patient before engaging with the physician or participating in multidisciplinary rounds or huddles.
Active participation in interdisciplinary rounds or huddles is expected, ensuring that the patient is making progress through clinical milestones and adjusting the targeted discharge date as needed.Collaboration with team members is vital to continuously identify and implement more effective strategies to address barriers, enhance processes and systems, and modify practices as necessary.
Any barriers to the care plan (clinical, social, or environmental) should be escalated through the appropriate channels for resolution. The role also involves working closely with physicians to evaluate alternative levels of care if the patient does not meet acute care criteria. Facilitating communication among physicians involved in the patient's care is essential to advance the care plan. Monitoring and documenting avoidable days and anticipated discharge dates in the medical record for all patients is a key responsibility.Additionally, planning for medical discharge needs is crucial.
Collaboration with Social Work is necessary to address the needs of patients with high-acuity psychosocial challenges who also require medical post-acute care, ensuring successful reintegration into the community and minimizing the risk of readmission.
Supporting the efforts of Health Information Management (HIM) and Patient Accounts by ensuring timely, accurate, and complete data entry across multiple information systems and databases is also part of the role.
The Registered Nurse Case Coordinator is expected to perform all duties in alignment with the mission, vision, and values of Tampa General Hospital.In addition to the aforementioned responsibilities, the Emergency Department Care Coordinator (CC) is tasked with providing effective hand-off communication to acute care staff, directing patient assignments to the appropriate admitting or Hospitalist service, leading consultations regarding optimal bed placement, and identifying and diverting unnecessary admissions from the Emergency Department to community-based providers.
The Emergency Department Care Coordinators will also identify patients with frequent admissions and collaborate with Social Work and community-based providers to reduce Emergency Department over-utilization.Creating, implementing, and updating a Patient Specific Action Plan (PSAP) for frequent Emergency Department users, and communicating this plan to all members of the Interdisciplinary Team with each hospital admission is crucial.
Identifying and ensuring documentation of conditions that may be present upon admission is also a key responsibility.Key Responsibilities:
- Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including thorough documentation in the medical record.
- Interprets and integrates the patient's narrative into the overall multidisciplinary care plan.
- Facilitates access to services and patient care progression using best practice interventions aimed at achieving favorable patient outcomes within a targeted length of stay.
- Collaborates with physicians, nursing staff, social work, and various disciplines, departments, payers, and agencies to eliminate barriers to efficient care delivery in the appropriate setting.
- Utilizes the Physician Advisor as per protocol for complex issues related to physician practices or behaviors, determining next steps for the patient and physician.
- Leads or co-leads Care Coordination Rounds as per policy and refers patients for Complex Care Rounds.
- Actively engages in clinical performance improvement initiatives as assigned.
- Builds a network of positive working relationships that advocate for the patient.
- Conducts team meetings for all unplanned readmissions occurring within 30 days.
- Completes necessary paperwork to facilitate the patient's transition through various levels of care.
- Graduate of an accredited School of Nursing; Associate's Degree required.
- Licensure to practice as a Registered Nurse in the State of Florida.
- Five (5) years of nursing experience, with at least two (2) years in Case Management or two years in Emergency Medicine.
