Transitional Case Manager
Company: Baptist Home Care & Hospice / Southaven
Location: Southaven
Posted on: April 19, 2024
Job Description:
The Transitional Case Managers(TCM) primary responsibility is to
facilitate a seamless transition for patients discharging from a
facility setting to the care of an LHC Group agency for post-acute
care needs. Included and aligned within this responsibility is the
understanding and implementation of company market development
initiatives and their role in growth as we focus on serving more
patients and delivering exceptional care. The TCM will verify home
health orders, assess the care required, and ensure continuity of
care and the agency's ability to meet the needs of the patient.
This clinical liaison position will assess each patient to
determine their level of health literacy and be adept at ensuring
the patients and families are included in care planning. Following
identification of needs the TCM will begin best practice
intervention and education to improve patient outcomes and promote
patient self-management. The TCM will implement rehospitalization
reduction initiatives for patients with Acute Care Hospitalization
risk and continually communicate between healthcare providers
during all phases of transition from the facility into the home.
-RN or LPN Required
- Identifies primary care physician to follow the plan of
care
- Educates patient on importance of the post facility discharge
follow up appointment with the physician
- Assess patient's risk for readmission using LACE tool and
documents in Transition encounterEducates patient on homebound
criteria and verifies patient meets these requirements
- Educates LHC Group referrals on Call First process and ensures
patient and family have agency contact information
- Educates patient on obtaining all necessary prescriptions prior
to discharge from hospital and confirms patient's understanding of
medication, pharmacy, and delivery method
- Coordinates other ancillary services for the patient
(DME-Infusion) as needed
- Assists the LHC Group agency in preparation of accepting care
of the patient post discharge
- Serves as a liaison between the LHC Group agency and all
involved healthcare providers of newly referred patients as well as
existing patients transferred to the hospital from the home health
agency
- Communicates to discharge planning any active patients that
transfer from home health into a Facility and coordinates
resumption of care with patient prior to discharge if applicable
orders are obtained
- Provides follow up feedback to case management team regarding
status of readmissions and any non-admit decisions based on
information provided to them by the LHC agency
- Serves on facility committees, if requested, and works with
hospital focus groups to assist in systems integration and process
improvements which result in improved patient outcomes and
transitions of care as approved by Director
- Participates in monthly Executive Director and Account
Executive meetings to assist with clinical program needs
- Attends all Department calls and company provided
in-services
- Observes patient confidentiality at all times
- Provides education in-services to effectively communicate the
features, benefits, and specialty programs of LHC Group and to
educate referral sources as to what services are available in the
home
- Demonstrates a desire to promote the LHC philosophy, "It's All
about Helping People" and seeks ways to facilitate helping more
patients
- Communicates with growth team and continually analyzes best
practices and opportunities to provide care to and reach any
underserved population within our service areas
- Meets personal performance goals established by manager
- Documents Start of Care transition CTC encounter note within
24hrs of patient referral/ agency acceptance and update as status
of patient transfer changes
- Documenst Resumption of Care note if applicable
- CMCN to be obtained within first year of employment
- All other duties as assigned
Experience Requirements
- -Must have one year home health experience or one year of
hospital case management experience.License Requirements
- -Must have current RN or LPN or SW licensure in state of
practice
- -Reliable means of transportation and must have current
driver's license and auto insuranceSkill Requirements
- -Must have excellent verbal and written communication skills
with all members of the healthcare team
- -Must have excellent organizational skills and ability to
complete competing priorities
- -Must have thorough understanding of home health qualifying
criteria and coverage guidelines
- -Proficient computer skills.
Keywords: Baptist Home Care & Hospice / Southaven, Southaven , Transitional Case Manager, Executive , Southaven, Mississippi
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