The Transition Case Manager oversees HSC patients’ progression to the appropriate discharge disposition through individualized care coordination and discharge planning. The Transition Case Manager, in collaboration with nursing, medical and rehab staffs, is responsible and accountable for ongoing assessing, planning, implementing and evaluating Patient-Caregiver discharge teaching needs.
Essential job duties:
1. Identification of preliminary discharge needs at time of Case Manager Admission Assessment. At that time, instructs patient, family/caregivers at that time about the discharge planning process; and, the importance of their participation in that process.
2. Acts as a liaison between HSC staff, patients, caregivers and community discharge resources.
3. Develops and maintains ongoing relationships and communication with Clinical and Medical staff; as well as community resources (external hospital staffs, home care agencies, outpatient therapy providers, DME companies, pharmacies, transportation companies, etc.) regarding patients requiring post hospitalization services through discharge.
4. Makes appropriate referrals to community agencies in preparation for discharge; and coordinates communication between family/caregivers and the agencies. Follows up on concerns identified by community agencies about the appropriateness of the discharge plan.
5. Ensures discharge medications and durable medical equipment are ordered in a timely manner.
6. Ensures patient, family or caregiver has identified a Primary Care Provider (PCP) and scheduled a post-discharge follow up appointment. Schedules PCP appointment, if patient or caregiver has difficulty doing so. Schedules follow up appointments.
7. Facilitation of weekly Interdisciplinary (IDT) Rounds; and participation in the development of the Inpatient Plan of Care with the IDT.
8. Identification of Patient-Caregiver learning needs – established at first IDT Rounds.
9. Establishment of individualized Teaching Plans, including timelines, with family (adjusted as needed). Provision of ongoing teaching of identified required education to Patient/Caregivers towards goal of discharge readiness. Documentation of education on the appropriate teaching record(s).
10. Ongoing communication with nursing staff re: education provided and portions requiring Nursing reinforcement.
11. Reports teaching progress at weekly IDT Rounds, including readiness for discharge.
12. Coordinates Family Meetings with Unit Social Worker to assess patient and family/caregiver readiness for discharge.
13. Coordinates Family Apartment Stays with Unit Social Worker to assess patient and family/caregiver readiness for discharge.
14. Arranges discharge transportation, as needed.
15. Addresses last minute patient, family/caregiver questions/concerns at the time of discharge; including additional discharge teaching on medications and follow up appointments.
16. Completes the Case Management-Social Work Discharge Summary with the Social Worker. Provides copies to patient, family and/or caregiver, PCP and appropriate healthcare providers, as needed.
Other job duties:
1. Schedule Clinic Appointments for in house patients.
2. As needed coverage for the Admissions Case Manager and UM/UR Nurse.
3. Other duties as required.
Must have three (3) to five (5) years of clinical experience in NICU, PICU or Pediatric Nursing. Demonstrated knowledge and skills necessary to provide age appropriate care to the patients served by the hospital; including knowledge of growth and development principles over the life span. Highly developed communication and organizational skills. Ability to communicate effectively with internal and external individuals and groups of all levels. Able to manage multiple priorities. Bilingual in Spanish highly preferred.
Registered Nurse licensure from the District of Columbia; current CPR certification; certification in Pediatric Nursing and/or certification in Case Management preferred.
Associate’s degree in Nursing, BSN degree preferred.