RN - Inpatient Care Coordinator
Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. Utilizes the five components of case management: assessment, coordination, monitoring, implementation, and evaluation.
- Act as a laison working with patient/family and physician to determine next level of care
- Conducts case review presentations to educate peers on unique or challenging cases and scope of practice issues.
- Coordinates the transition from inpatient care to post-hospital care, working with pre- and post- hospital providers to ensure responsive and appropriate care is provided post-discharge.
- Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients.
- Evaluates effectiveness of plan of care to ensure the progression toward desired patient outcomes.
- Initiates intervention, both pre-hospital, in-hospital, and post-hospital, for patients and families identified from a proactive initial admission assessment, as well as through referrals from members of the healthcare team.
- Initiates timely referrals to other healthcare team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)
- Performs case management activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education.
- Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider.
- Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs.
- Track avoidable days on inpatient stays.
- Readmission assessment of inpatient stays.
- Assess patients for post discharge needs.
- Do secondary screening (trans plan evaluations ) on high risk patients
- Attend daily white board rounds
- Arrange DME, Home Care, Hospice, ECF Placement, and Transportation
- Deliver Observation Notification letters to patients who are observation when needed.
- Arrange/attend any patient/family care conferences.