Facilitate access to necessary services of eligible patients.
- Promotes effective and efficient utilization of clinical resources by Facilitating transfer and/or discharge at the earliest time possible.
- Assists the interdisciplinary team set approximate discharge and transfer dates at the time of admission.
2- Assessment/ Reassessment:
Completes a comprehensive case management assessment at time of admission, to identify patient needs, goals, abilities, resources, and supports as the basis for services planning.
- Conducts medical record review using specific indicators and criteria as approved by medical care team.
- Weekly meeting with chairman and heads of sections to review patients admission appointments and given them priority for admission.
- Assesses of appropriate patient care services throughout the continuum of care transferring and discharging patient based on identified health care needs.
3- Facilitation of Services Delivery and Care:
Coordinates, communicates and collaborates on behalf of the patient of the patient to achieve goals and maximize positive patient health outcomes.
- Mobilizes resources and conduct interviews, as needed, to achieve expected patient goals to assist in achieving desired clinical outcomes within the appropriate timeframe.
- Ensure that patient test results are available in a timely fashion.
Works with others in a way that promotes and encourages each person’s contributions toward achieving optimal goals.
- Collaborates with the health care delivery team to achieve patient goals.
- Coordinates the integration of social services/case management function into patient care, discharge, and home planning process with other hospitals departments, external service organizations, agencies and healthcare facilities.
Works with the interdisciplinary team to develop evidence based plan of care that is individualized to meet the patient’s needs.
-Refers cases to other services /department where patient and/or family would benefit from counseling or services to complete complex discharge plan.
Advocates understanding and respect for the beliefs, value system and decisions of the patient. Works on the patient’s behalf to ensure safety and well-being.
-Investigates and reports adverse occurrences related to resource utilization. Discharge planning, and psychosocial aspects of healthcare delivery.
Communicates with physicians and the health care delivery system and establishes effective working relationships.
Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize hospital resources utilization by timely patient transfer and discharge, and help in providing family education and identify discharge needs.
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8- Clinical Judgment:
Utilizes sounds clinical reasoning, which includes clinical decisions making, critical thinking, and a global grasp of the situation.
9- Clinical Inquiry:
Utilizes an ongoing process of questioning and evaluating own practice and making adjustments to improve practice.
10- Caring Practices:
Responds to the patient to create a compassionate and the therapeutic environment by promoting comfort, well-being, and safety.
a- Evaluates for patient satisfaction and ensures quality of care is provided.
b- Introduce self to patient and family and explains case manager roles and the process of patient and family to contact case manager.
11- Systems Thinking:
Utilizes the body of knowledge from a perspective that recognizes the holistic interrelationship that exists across healthcare system and within a healthcare system.
12- Response to Diversity:
Recognizes and incorporates different views in the provision of care.
13- Supervisor/Management Review:
Accepts direction and feedback from the supervisor.
Direct and give task to employees.
14- Monitoring, Evaluation and Review:
Monitors the delivery of services and evaluates patient outcomes and makes revisions as indicated.
a- Conduct review to evaluate appropriate utilization of services from admission through discharge to ensure patients are in the appropriate level of care.
b- Evaluates patient progress through expected hospital course
15- High Risk/Special Needs Consumers:
Uses risk management mechanisms to address high-risk situation and special needs of patients.
a- May complete incident report.
b- Provides input into incident and high risk patient situations.
16- Changes in Service Status:
Modifies the case management plan based on the status of the patient without disruption of services or threat to patient health and safety.
17- Confidentiality :
Ensures confidentiality according to all relevant laws and regulations.
18- Reporting and Recordkeeping:
Maintains appropriates and adequate records to documents activity in the performance of responsibility as a component of the service delivery system.
a- Record finding of interdisciplinary team meetings on the team conference form.
b- Document patient progress every 24 hours in the progress notes and the plan for case management in the patient progress notes. (Waiting for approval)
19- Preceptorship :
Assists to train and educate new case managers.
Participates in all other job duties as requested and/or assigned.
Participates in all training and continuing education as required.