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OverviewThe RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.
Specific functions within this role include:
•Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
•Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
•Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
•Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
•Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
•Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
•May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
•Supports leaders in negotiating agreements with community agencies and facilities.
•May have other duties assigned as it relates to hospital complex patient population
ResponsibilitiesCore Responsibilites and Essential Functions
Assessment
* a.Based on preliminary screening of patients, initiates assessment of patient’s psychosocial risk factors and availability of resources to assist upon discharge.
b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patient’s care progression and discharge plans.
Complex Disposition Planning
* a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients.
b.Identifies and documents barriers for timely disposition.
c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
d.Responds to referrals for patient assistance from RN physicians and the care team.
e.Participates in Interdisciplinary Rounds with the patient’s care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
j.Arranges and facilitates family meetings when needed.
k.Allows for any cultural or religious beliefs in providing service and continuity of care. 3.Documentation
a.Initial psychosocial /functional assessment completed and documented in medical record.
b.Ensure all records are up-to-date and documentation is understandable.
c.Ensure timely and accurate documentation of progress notes and interactions with patient/family.
d.Accounts for and indicates all services arranged/delivered in Electronic Health Record.
e.Enter avoidable days, when applicable, in the Electronic Health Record.
Professional Development and Initiative
*a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
b.Supports departmental- based goals which contribute to the success of the organization.
c.Participates in the development of protocols, procedures and performance improvement as indicated
to optimize patient outcomes.
4.Precepting/Mentoring
a.Assist leadership with precepting new hires when needed.
b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
c.Serves as a preceptor and/or mentor for student interns
4.Precepting/Mentoring
a.Assist leadership with precepting new hires when needed.
b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
c.Serves as a preceptor and/or mentor for student interns
4.Precepting/Mentoring
a.Assist leadership with precepting new hires when needed.
b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
c.Serves as a preceptor and/or mentor for student interns
Required for All Jobs
Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct. QualificationsRequired Minimum Education
Bachelor's Degree in Social Work or a master’s degree in Social Work from an accredited college or university. Required or Bachelor's Degree in Nursing Required Required Minimum Experience
Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and Minimum 2 years in care coordination in the acute care setting. Required Required Minimum Skills
Excellent written and verbal communication skill. Must possess maturity, self-confidence, objectivity, and positive attitude. Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment Strong assessment, interview, organizational and problem-solving skills. Knowledge regarding local, state and federal regulations required. Knowledge of community and state-wide resources and programs. Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care. Required Minimum License(s) and Certification(s)
Reg Nurse - Board Cert Required RN - Multi-state Compact Required Basic Life Support Required BLS - Instructor Required BLS - Provisional Required Accredited Case Manager Preferred Certified Case Manager Preferred Additional Licenses and Certifications
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