Case Manager Nurse Discharge Planner

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

• Responsible for coordinating all post-acute services for inpatient and outpatient services. Interview patients and families, assess aftercare options and provide information, guidance, and support in decision-making. The Case Manager provides emotional support to caregivers and collaborates with peers, physicians, other departments, and community agencies to expedite placements. Work with patients and families to help them understand the impact their illness may/will have on their lifestyle, family relationships and home situation.

Responsibilities:

• Discharge Planning Competencies:Interview and collaborate with patients/family to assess aftercare options while providing guidance information and support in decision makingCoordinate all aspects of the discharge process for patients post-acute needs returning homeDevelops alternative discharge plans and coordinates with Manager and peers as needed to facilitate resolution of problem dispositions or difficult patients/families.Facilitates and monitors the discharge plans and arrangements for assigned patients going to boarding homes, assisted living, skilled care, long term care, hospice, or rehabilitation (physical, drug and/or alcohol).Refer to community services as needed, including (but not limited to): Office of Aging, CYS, CVIM, MH/IDD, crisis, domestic violence, dialysis services, VNA, etc.Work with patients and their families to help them understand the impact their illness may have on their lifestyle, family, relationships, and home situation.Coordinate individual patient care conferences when deemed necessary, including appropriate inpatient and outpatient personnel/agencies.Develops a discharge plan in a timely manner to maintain lowest cost to the hospital, while ensuring a comprehensive quality plan.Procures signature on Medicare Outpatient Observation Notice (MOON) form and second signature on Medicare Important Message (IMM) form for assigned patients as required by CMS 48 hours prior to discharge.Intervention Competencies:Discuss the plan of care and targeted length of stay with the multidisciplinary team, patients, and family at the time of admission.Explore strategies to reduce the length of stay and resource consumption.Serve as a patient advocate with the health care team, payors and outside agencies.Collaborate with primary nurses to identify plans to maintain streamlined patient care.Participates in the daily discharge rapid rounds (multidisciplinary team meetings) coming prepared with essential information.Identifies a plan with the Case Management Director and/or Manager to address system opportunities and participates in that planIntervention Competencies:Discuss the plan of care and targeted length of stay with the multidisciplinary team, patients, and family at the time of admission.Explore strategies to reduce the length of stay and resource consumption.Serve as a patient advocate with the health care team, payors and outside agencies.Collaborate with primary nurses to identify plans to maintain streamlined patient care.Participates in the daily discharge rapid rounds (multidisciplinary team meetings) coming prepared with essential information.Identifies a plan with the Case Management Director and/or Manager to address system opportunities and participates in that planCommunication Competencies:Communicate patient needs to medical staff, nursing staff, Case Management team, and Physician Advisor as appropriate.Communicate patient needs, with attention to details, to service providers to insure safe level of care and appropriate resources after discharge.Communicate with medical staff regarding case management issues as they occur and document in EMRCommunicate with ancillary departments to negotiate accelerated test scheduling to receive results not yet available in EMR or ensure interaction with patient as ordered by physician.Documentation Competencies:Record all patient/family activity, interaction or intervention related to discharge planning on the medical record using the EMRDocument action taken related to discharge planning within same day of interaction with patient/family and/or physician.

Credentials:

• RN or MSW (Required)

• RN if not an MSW

• Certified Case Manager

Education or Equivalent Experience:

• Other

• MSW Social Work or BSN Nursingor 5+ years RN or BSW with a minimum of 5 years Case Mangement experience.

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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