Participates in the assessment of patient clinical and psychosocial needs through review of patient information, personal contact with patient/family, and interdisciplinary care team members.Communicates routinely with the patient, family, interdisciplinary care team members and other appropriate parties with regard to status of patient care plan and progress toward treatment goals, identification of concerns and/or problems, problem-solving and assisting with conflict resolution when necessary.Works with multi-disciplinary team to address/resolve system problems impeding diagnostic or treatment progress. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Ensures that all elements critical to the patient's care plan have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.Applies approved clinical criteria to monitor appropriateness of admissions, continued stays or post-acute setting appropriateness and documents findings based on department standards.Identifies at-risk populations using approved screening tool and follows established reporting procedures.Monitors LOS and ancillary resource use, depending on inpatient stay or outpatient program criteria, on an ongoing basis and takes actions to achieve continuous improvement efficiencies in both areas.Refers cases and issues appropriately to resolve barriers to care progression.Collects delay and other data for specific performance and/or outcome indicators.Assists in the collection and reporting of resource and financial indicators including acute and post-acute case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals.Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, chronic disease planning). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization. Initiates and facilitates referrals to clinics, home health care, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies, as indicated.Collaborates with interdisciplinary care team, patient and family in the assessment and coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of the patient from the hospital to the discharge setting, as well as ongoing care in the community.Documents relevant discharge planning information in the medical record according to department standards, and/or care management plan.Collaborates/communicates with internal and external case managers.Work closely with the members of the patient's healthcare team to manage and coordinate all areas of the patient's care.Work holistically to ensure that care plans and discharge plans meet the physical, social, and emotional needs of patients.Provides educational resources and/or referrals to the patient and patient's family to address identified needs such as social or financial.Acts as patient's advocate to resolve barriers to care progression.
Internal Number: 50900BR
About Inova Health System
Inova is a global leader in personalized health, which leverages precision medicine to predict, prevent and treat disease, enabling individuals to live longer, healthier lives. At Inova, we serve more than two million people each year from throughout the Washington, DC, metro area and beyond. Inova's mission is to improve the health of the diverse community it serves through excellence in patient care, education and research. At Inova, more than 16,000 employees demonstrate their commitment every day to providing the community with expert, world-class, compassionate patient care.