Care Coordination RN

Performs Discharge Planning evaluations including risk assessments for defined population within expected time frame Provides Assessment and ongoing reassessment of a patient's diagnosis, prognosis, and anticipated care needs and goals. Collaborates with other disciplines; actively participates in interdisciplinary rounds. Collaboration includes progression of care, appropriate length of stay, integration of risk factors to reduce readmission, and integration for the care plan. Collaborates with the social worker daily to identify patients in need of social work intervention or with potential post-hospital discharge needs. Intervenes and educates patients and families regarding anticipated complex home care needs including providers which are applicable to the patient’s goals and treatment preferences. Utilizes teach back methodology. Obtains patient choice for skilled home care providers and educates about payer in-network providers. Coordinates complex home care plan including referrals for patients, anticipating time frames for discharge, and updating the patient/family accordingly. Ensures that necessary skilled home care, medical equipment/supplies, and medications are in place by the time the patient is discharged. Educates about and delivers Beneficiary notifications, including Important Message from Medicare, Detailed Notices, Observation Notices, and HINN’s within expected time frames. Coordinates acute to acute hospital transfers and transports as requested within assignment area. Documents in the electronic medical record, including updating the Interdisciplinary Plan of Care and Case Management software as per Department protocol. Ensures handoff as per department protocol.