Cross Continuum Care Manager-RN-Family and Internal Medicine Clinic

Overview:
The care manager provides care management and population health services to patients within an assigned region. The primary target population to serve is the stratified risk patient or patients with high vulnerability at times of transition between care settings.

 

Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care team across the continuum, and increasingly use data analytics to manage the health of populations to improve patient access to care and clinical outcomes.

 

 

 

 

Why UnityPoint Health? 

Commitment to our Team – We’ve been named a by Becker’s Healthcare for our commitment to our team members. 

Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience guided by uncompromising values and unwavering belief in doing what's right for the people we serve. 

Benefits – Our competitive program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. 

Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation. 

Development – We believe equipping you with support and is an essential part of delivering a remarkable employment experience. 

Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve. 

 

Visit us at (url removed)/careers to hear more from our team members about why UnityPoint Health is a great place to work.  

Responsibilities:
Longitudinal care planning

• Conducts in depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the stratified risk patients

o Holistic health care assessment includes: health risks, patient preferences and goals,

health literacy, patient engagement level, patient confidence level to perform self-

management, impact of chronic health conditions and comorbidity, and social determinants

of health.

• Delegates care based on situation while assuming accountability for patient outcome.

Supports assistive personnel; serves as a resource and holds care team accountable to

complete delegated tasks.

• Develops shared care plan and document on the Common Care Plan to allow access by all

care team members across the care continuum.

 

• Advance Care Planning

o Connects patient and surrogate decision maker to ACP facilitation process.

o Ensure that Advance Care Planning documents are stored and available within the

EHR

 

• Performs outreach utilizing best practices to engage appropriate patients for care management. 

Medication Management • Reconcile discharge medication orders, medication orders by specialists and PCP. Collaborate with PCP/Interdisciplinary team members on medication changes as needed. • Ensure patient understanding of any medications to stop taking or initiate. • Be clear to patient why medications were discontinued. Psycho-social support § Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners). § Ensure that all members of the care team are aware of barriers, assets, and action plans. § Access 2-1-1 for community resources. § Supplement with internal database for community resources not available through 2-1-1. Communication and coordination between care settings • Working with the Intellicenter team, physician hospitalists/PCPs/specialists, leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care. • Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families and providers. • Functions as a coordinator and manager of a defined health population across multiple care settings and for multiple physicians/health care providers or health plan counterparts. • Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources o Coordinate referrals processes from PCP to Specialty o Provides oversight if patient transitions to SNF and monitor progress throughout the patient stay. o Uses technology platform(s) to monitor and act upon changes in condition as directed by the primary care provider o Ensure post SNF transition plan is completed for Post-discharge call and follow up appointment is scheduled with PCP. o Coordinates access to resources and supports to achieve the goals of care such as specialists, homecare, palliative, hospice and other community services. o Initiates post transition phone calls to high risk / high vulnerability patients to assess self-management and to identify risk prior to their first appointment. o Position Home Care to assist with evening and w/e ED cases to avoid admissions, similar to 3-day waiver and admission to SNF vs. IP • Participate in Readmission Root Cause Analysis • Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting. o Initiate IDT/SWAT TEAM for patients with IP stay of 5 days or more. • Identify transition needs when connecting back to PCP • Ensure that patient discharge appointments are consistent with predictive risk of readmission, i.e. Heat Map Ensure consistent care management outreach follow up for those declining Home Care

Education

 

 

· Assesses patient/family knowledge and confidence level of chronic disease self -management and

refers to internal and external resources to meet identified gaps.

· Reinforces education regarding chronic disease self- management utilizing approved action plans,

educational materials and best practice recommendations.

o Facilitates health and disease specific patient education utilizing Teachback

o Utilizes and educates patient on Healthwise tools

· Coordinates education regarding internal resources and other community support services to the

healthcare team, i.e. wound care team, Diabetic Educators, Respiratory Therapy or PT. 20%

· Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization. o Encourages enrollment in patient portal and access to Healthwise Knowledge base through portal

Data Analytics

· Identify appropriate risk stratification via EHR encounters or datasets to intervene as

appropriate

· Integrate patient registry, stratification and other tools/reports to identify patients who may be

appropriate for care management.

· Manages risk stratified patient care, including management of patients with multiple co-morbidities or high risk for admission or readmission to a hospital setting, using a registry

· Analyzes data to identify under/over utilization; improve resources consumption; promotes

potential reduction in cost; and enhances quality of care consistent with organization strategic

goals and objectives. Data includes but is not limited to predictive analysis, risk stratification,

cost-benefit analyses, financial analyses; clinical outcomes; utilization and practice patterns

· Utilize dashboards or other reporting mechanisms to support performance improvement and

outcome evaluation

· Implement real time alerts to indicate when individuals are accessing the healthcare system

or experiencing issues that could impact their health

Qualifications:
Education:

Graduate of an accredited program for Registered Nurses. Bachelors of Science in Nursing (BSN)

 

 

Experience:

3 year clinical nursing experience Previous clinical experience in a clinic or Home Care setting. Previous experience with care coordination /care management and population health.

 

License(s)/Certification(s):

Current license in good standing to practice nursing in the state where care is provided. Basic Life Support (BLS) certification required for team members that perform the majority of their work in the clinic setting. BLS certification optional for team members that perform the majority of their work at a remote location. (Remote Work policy referenced here) Valid driver’s license when driving any vehicle for work-related reasons.

 

Knowledge/Skills/Abilities:

· Basic computer knowledge using email, web browser and documentation of care in an electronic health record

· Knowledge of the healthcare system and resources available to patients.

· Strong clinical proficiency and ability to apply critical decision making in dynamic situations.

· Motivational Interviewing and applies Integrated Chronic Care Management skills.

· Cultural compliance

· Trauma informed care

· Ability to problem solve in complex situations.

· Strong interpersonal skills and ability to collaborate.

· Excellent communication skills-written and verbal

· Strong self-motivation and ability to work independently, setting priorities to coordinate care plan efficiently

· Proven leadership skills

· Ability to function effectively as a team leader in a team based environment.

· Patient focused · Excellent customer service skills

· Strong organizational skills and ability to efficiently use tools and resources.

· Ability to perform multiple tasks

· Effective behavioral and educational strategies, including, but not limited to, motivational interviewing, teach-back method and self-management support