The Registered Nurse (RN) Complex Case Manager (CCM) is responsible for providing case management services for the medically complex inpatients The patient population covered will include significantly complex medical conditions, and/or social-economic and mental health co-morbidities. The goal of the program will be to assist these patients to achieve optimal health and/or independence in managing their care. To achieve this goal the manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination and management of complex patients. The case manager will be responsible to develop plans for patient and family self-care competence, including motivational assessment, assessing for desired level of involvement and coaching for adherence to care plan. CCM will provide nursing assessment, create and monitor patient/family care plans, including end of life planning.
Bachelors¿ degree in nursing or related field OR ADN with 5 years of case management experience with BSN completion within 5 years of hire required.
1. Assess the physical, functional, social, psychological, environmental, learning and financial needs of patients.
2. Identify problems, goals and interventions designed to meet patient's needs, including prioritized goals that consider the patient/caregivers goals, preferences and desired level of involvement in the case management plan.
3. Assist with creation of IP care plan including objectives, goals and actions designed to meet patient's needs.
4. Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
5. Assess the patient's formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources.
6. Implement and monitor the IP care plan to ensure the effectiveness and appropriateness of services. Maintain ongoing communication with UR Nurse regarding same.
7. Evaluate patient's progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status.
8. Research alternative treatment options and selecting and locating appropriate providers which can include facilitation of referrals.
9. Communicates with attending and primary care physician and members of the comprehensive care team regarding status of patient.
10. Utilize motivational interviewing skills to build patient engagement in case management plan of care.
11. Provide education, information, direction and support related to care goals of patients.
12. Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
13. Coordinate care and develop treatment plans.
14. Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved. coordinate discharge services to avoid duplication.
15. Maintain accurate patient records and patient confidentiality.
16. Measure outcomes and effectiveness of case management including clinical, financial, quality of life and patient/family satisfaction.
17. Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.
18. Facilitate disease prevention and health promotion with patients and families
19. Determine psychosocial needs & complex medical needs of all patients
20. Troubleshoots problems regarding operational and clinical procedures that may affect patient outcomes.
21. Attend mandatory training sessions and staff meetings as assigned.
22. Participate in prospective, concurrent, and retrospective case reviews involving targeted patients.
23. Identify risk factors and teach patients clear pathway of response to identified triggers
24. Promote patient and family responsibility and self-management
25. Document all relevant information following department policy guidelines.
26. Maintain knowledge of operational procedures and case management program components.
27. Promote chronic disease management concepts, health screening and preventive health initiatives for targeted patients
28. Participate and promote appropriate performance improvement projects Program Development:
29.Assist with the collection, analysis, and benchmarking of utilization data.
30. Collaborate in the development of protocols and guidelines for patient care management.
31. Adhere and uphold Beebe Healthcare's Mission, Vision and Values and Performance Standards
Beebe Healthcare serves the Sussex County community with a medical center located in beautiful, historic Lewes, Delaware, and convenient outpatient locations throughout the county. Founded in 1916 by two physician brothers, Drs. James Beebe and Richard C. Beebe, the medical center in Lewes is a 210-licensed-bed, not-for-profit seaside community hospital. Beebe's specialized service lines include cardiac and vascular, surgical services, oncology, women's health, and orthopaedic services. Beebe offers an array of inpatient, outpatient, emergency, and diagnostic services.
Beebe's five satellite campuses offer imaging, physical rehabilitation, and lab services, as well as walk-in care centers. In addition, Beebe offers Wound Healing & Hyperbaric Medicine and Diabetes Management & Medical Nutrition Therapy.
With a mission to serve the community, Beebe also offers many free screenings and outreach programs through its Population Health Department; and advanced medical care for those who are recuperating at home through Beebe Home Care Services.
Beebe is also training the next generation of nurses through the Margaret H. Rollins School of Nursing, located behind the Medical Cente...r in Lewes.
Beebe's Medical Staff has grown tremendously since the early 1990s. Employed physicians through Beebe Medical Group and our affiliated physicians on Beebe's Medical Staff now serve patients from Milford to Millville in specialties including cardiac surgery, dermatology, endocrinology, family practice, gastroenterology, general surgery, internal medicine, pediatric neurology, and surgical oncology.
Beebe is proud to offer quality care, close to home for the residents and visitors of Sussex County.
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