RN - Clinical Transition Specialist (Discharge Planning)
Company: CARLE
Location: Heyworth
Posted on: May 24, 2023
Job Description:
Responsible for the oversight, coordination, and management of
the functional and financial outcomes during acute illness
requiring hospitalization for patients of the Carle Foundation
Hospital. Ensures patients receive proactive initial assessment of
needs, ongoing evaluations, and initiation of discharge planning
while facilitating a safe and timely transition from the acute
care/hospital setting to an appropriate level of care outside the
hospital. Utilizes the five components of case management:
assessment, coordination, monitoring, implementation, and
evaluation.
- Act as a liaison working with patient/family and physician to
determine next level of care
- Conducts case review presentations to educate peers on unique
or challenging cases and scope of practice issues.
- Coordinates the transition from inpatient care to post-hospital
care, working with pre- and post- hospital providers to ensure
responsive and appropriate care is provided post-discharge.
- Documents plan of care and utilization issues in appropriate
locations, including but not limited to: case
management/utilization review software and the multidisciplinary
plan of care document on all assigned patients.
- Evaluates effectiveness of plan of care to ensure the
progression toward desired patient outcomes.
- Initiates intervention, both pre-hospital, in-hospital, and
post-hospital, for patients and families identified from a
proactive initial admission assessment, as well as through
referrals from members of the health care team.
- Initiates timely referrals to other health care team members
(quality improvement, risk manager, social workers, physicians,
Home Services, etc.)
- Performs nursing activities of assessment, coordination,
planning, monitoring, implementation, and evaluation. Interacts
with clients, caregivers and families to assess, plan care, arrange
services, monitor, and provide support and education.
- Proactively investigates coverage for post-hospital needs and
presents options to the patient/family and provider.
- Provides oversight of acute setting plan of care to ensure
coordination and completion of services to meet
post-hospitalization needs.
- Lead an interdisciplinary team to achieve organizational goals
related to length of stay and readmissions.
- Track avoidable days on inpatient stays.
- Readmission assessment of inpatient stays.
- Assess patients for post discharge needs.
- Participate in daily white board rounds.
- Arrange DME, Home Care, Hospice, assisting with returns to
ECFs, and Transportation
- Assist any patient/family care conferences.
- Participate in department work groups.
- HRHC: make follow up appointments with primary care provider
before patient discharges, makes post discharge phone calls to
ensure patient is doing well and has what they need for success.
Obtain prior authorizations for swing bed patients, maintain the
work ques, and address denials.
- RMH: make follow up appointments with primary care provider
before patient discharges, makes post discharge phone calls to
ensure patient is doing well and has what they need for success.
Initial utilization review for emergency room patients being
admitted.
Keywords: CARLE, Bloomington , RN - Clinical Transition Specialist (Discharge Planning), Healthcare , Heyworth, Illinois
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