Complex Care Coordinator
Munson Medical Center
 Cadillac, MI

SUMMARY Working in partnership with the unit nurse, case manager, physician and patient, identifies patients with complex post-acute needs and facilitates the development of a safe discharge plan. The CCC is responsible for assessing the patient#s continuum of care needs, developing a plan in collaboration with the patient the healthcare team, and implementing the plan using the resources of the Resource Center.# The CCC serves as an advocate for the patient and family throughout the entire process. ELIGIBILITY REQUIREMENTS Bachelor#s degree in Nursing with RN licensure in the State of Michigan-or- Bachelor#s degree in Social Work with licensure as a Social Worker in the State of Michigan.# A Master#s degree in Social Work is preferred. A minimum of three years experience in the hospital or medical insurance industry. Other clinical or behavioral disciplines with comparable experience will be considered. Knowledge of Case Management Society of America#s case management standards of practice.# Eligible to sit for, and successfully pass, the test for certification as a Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of employment. Demonstrates outstanding communication skills and is able to establish constructive relationships with patients, families and other members of the health care team. ORGANIZATION #### Reports to the Manager of Case Management. AGE OF PATIENTS POPULATIONS SERVED #### Cares for patients in the age category(s) checked below: ###### __Neonatal (birth-1 mo)################################## __Young adult (18 yr-25 yrs) ###### __Infant (1 mo-1 yr)######################################### __Adult (26 yrs-54 yrs) ###### __ Early childhood (1 yr-5 yrs)############ ########### __ Sr. Adult (55 yrs-64 yrs) ###### __Late childhood (6 yrs-12 yrs)###################### __Geriatric (65 yrs # above) ###### __Adolescence (13 yrs-17 yrs)####################### _X_All ages (birth # above) ###### __No direct clinical contact with patients SPECIFIC DUTIES Supports the Mission, Vision and Values of Munson Healthcare Embraces and supports the Performance Improvement philosophy of Munson Healthcare. Promotes personal and patient safety. Has basic understanding of Relationship-Based Care (RBC) principles, meets expectations outlined in Commitment To My Co-workers, and supports RBC unit action plans. Uses effective customer service/interpersonal skills at all times. Demonstrates ability to utilize systematic, creative, cost effective alternatives to meet patient and family needs.# Identifies need for, advocates for, and contributes to the creation of new resources to meet patient and family needs.# Is sought as a consultant by staff and other professionals in the area of transition planning. Performs assessment of patient#s probable post-acute needs in light of patient#s condition and prognosis and develops recommendations for transition.# Demonstrates high level of expertise in assessment of complex cases.# Demonstrates creativity in treatment plan development in spite of barriers or limited resources.# Identifies need for and recommends improvement in screening. Facilitates patient and family understanding and adjustment to illness through family conferences. Negotiates transition plan with patient, family and physician. Within the context of the patient#s financial resources # including insurance benefits - provides information on service and resource availability to the patient, family and staff. Maintains knowledge about and acts in accordance with law and procedures regarding patient confidentiality and release of information, legal requirements for reporting abuse, and advance directives. Conducts assessment of domestic abuse, child and adult welfare, and other psychosocial problems in the ED or Acute Care as indicated. Make mandatory referrals to appropriate governmental agencies and other referrals as necessary. Interprets nature of illness and prescribed course of post-acute treatment to patient/family.# Facilitates patient and/or family decision making regarding initiation and/or discontinuation of treatment, life supports, etc.# Facilitates communication between patient, family and health care team regarding medical recommendations. Uses interpersonal skills which convey a positive and supportive attitude (e.g., active listening, good communication, telephone etiquette). Prepares written reports, progress notes and other material that are concise and well- constructed for ease of reading by all healthcare team members. In preparing a recommendation for a post-acute plan, consistently demonstrates knowledge of human behavior, socioeconomic factors in disease and illness, behavior patterns of the physically and mentally ill patient. Communicates routinely and consistently with Case Manager #to share information, provide professional insights and offer recommendations. Identifies interventions that are consistent with the problems identified through involvement with the patient, family, Case manager, health care team and appropriate agencies. Patients and families are given guidance with regard to available entitlement programs or other financial resources. Continuously assesses patient and family readiness for post-acute transition and recommends alteration to the plans when appropriate. Determines the feasibility of the home environment when recommending post-acute plans.# May conduct onsite assessment of current living conditions with appropriate members of the healthcare team to determine the appropriateness of a plan for discharge to home. Maintains a working knowledge of community resources/referrals; provides options to patient/family and assists by initiating contacts and referrals when appropriate. Communicates status of the plan with physician, patient, family, case manager and other health care team members keeping them informed through participation in rounds, care conferences and medical record documentation. Demonstrates skill in documenting appropriate information in the medical record in clear, concise, logical, specific, and thorough manner. Evidenced through chart review.# Organizes patient/family conferences as needed to resolve placement issues or other discharge plan issues and documents outcome from conference. Facilitates transition activities in concert with colleagues in the Resource Center. Completes necessary forms that need evidence of professional interventions. Plan implementation is facilitated to assure that optimal patient progression-of-care is achieved.# Able to maintain flexible working hours to meet patient and family needs and to achieve plan and program outcomes. Works well under pressure of time and shifting priorities. Participates in initiatives to capture data on transition planning efficiency.# Performs other duties as required.

SUMMARY

Working in partnership with the unit nurse, case manager, physician and patient, identifies patients with complex post-acute needs and facilitates the development of a safe discharge plan. The CCC is responsible for assessing the patient's continuum of care needs, developing a plan in collaboration with the patient the healthcare team, and implementing the plan using the resources of the Resource Center. The CCC serves as an advocate for the patient and family throughout the entire process.

ELIGIBILITY REQUIREMENTS

Bachelor's degree in Nursing with RN licensure in the State of Michigan-or-

Bachelor's degree in Social Work with licensure as a Social Worker in the State of Michigan. A Master's degree in Social Work is preferred.

A minimum of three years experience in the hospital or medical insurance industry.

Other clinical or behavioral disciplines with comparable experience will be considered.

Knowledge of Case Management Society of America's case management standards of practice. Eligible to sit for, and successfully pass, the test for certification as a Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of employment.

Demonstrates outstanding communication skills and is able to establish constructive relationships with patients, families and other members of the health care team.

ORGANIZATION

Reports to the Manager of Case Management.

AGE OF PATIENTS POPULATIONS SERVED

Cares for patients in the age category(s) checked below:

__Neonatal (birth-1 mo) __Young adult (18 yr-25 yrs)

__Infant (1 mo-1 yr) __Adult (26 yrs-54 yrs)

__ Early childhood (1 yr-5 yrs) __ Sr. Adult (55 yrs-64 yrs)

__Late childhood (6 yrs-12 yrs) __Geriatric (65 yrs & above)

__Adolescence (13 yrs-17 yrs) _X_All ages (birth & above)

__No direct clinical contact with patients

SPECIFIC DUTIES

  • Supports the Mission, Vision and Values of Munson Healthcare
  • Embraces and supports the Performance Improvement philosophy of Munson Healthcare.
  • Promotes personal and patient safety.
  • Has basic understanding of Relationship-Based Care (RBC) principles, meets expectations outlined in Commitment To My Co-workers, and supports RBC unit action plans.
  • Uses effective customer service/interpersonal skills at all times.
  • Demonstrates ability to utilize systematic, creative, cost effective alternatives to meet patient and family needs. Identifies need for, advocates for, and contributes to the creation of new resources to meet patient and family needs. Is sought as a consultant by staff and other professionals in the area of transition planning.
  • Performs assessment of patient's probable post-acute needs in light of patient's condition and prognosis and develops recommendations for transition.
  • Demonstrates high level of expertise in assessment of complex cases. Demonstrates creativity in treatment plan development in spite of barriers or limited resources. Identifies need for and recommends improvement in screening.
  • Facilitates patient and family understanding and adjustment to illness through family conferences. Negotiates transition plan with patient, family and physician.
  • Within the context of the patient's financial resources – including insurance benefits - provides information on service and resource availability to the patient, family and staff.
  • Maintains knowledge about and acts in accordance with law and procedures regarding patient confidentiality and release of information, legal requirements for reporting abuse, and advance directives.
  • Conducts assessment of domestic abuse, child and adult welfare, and other psychosocial problems in the ED or Acute Care as indicated. Make mandatory referrals to appropriate governmental agencies and other referrals as necessary.
  • Interprets nature of illness and prescribed course of post-acute treatment to patient/family.
  • Facilitates patient and/or family decision making regarding initiation and/or discontinuation of treatment, life supports, etc. Facilitates communication between patient, family and health care team regarding medical recommendations.
  • Uses interpersonal skills which convey a positive and supportive attitude (e.g., active listening, good communication, telephone etiquette).
  • Prepares written reports, progress notes and other material that are concise and well- constructed for ease of reading by all healthcare team members. In preparing a recommendation for a post-acute plan, consistently demonstrates knowledge of human behavior, socioeconomic factors in disease and illness, behavior patterns of the physically and mentally ill patient.
  • Communicates routinely and consistently with Case Manager to share information, provide professional insights and offer recommendations.
  • Identifies interventions that are consistent with the problems identified through involvement with the patient, family, Case manager, health care team and appropriate agencies.
  • Patients and families are given guidance with regard to available entitlement programs or other financial resources.
  • Continuously assesses patient and family readiness for post-acute transition and recommends alteration to the plans when appropriate.
  • Determines the feasibility of the home environment when recommending post-acute plans.
  • May conduct onsite assessment of current living conditions with appropriate members of the healthcare team to determine the appropriateness of a plan for discharge to home.
  • Maintains a working knowledge of community resources/referrals; provides options to patient/family and assists by initiating contacts and referrals when appropriate.
  • Communicates status of the plan with physician, patient, family, case manager and other health care team members keeping them informed through participation in rounds, care conferences and medical record documentation.
  • Demonstrates skill in documenting appropriate information in the medical record in clear, concise, logical, specific, and thorough manner. Evidenced through chart review.
  • Organizes patient/family conferences as needed to resolve placement issues or other discharge plan issues and documents outcome from conference.
  • Facilitates transition activities in concert with colleagues in the Resource Center.
  • Completes necessary forms that need evidence of professional interventions.
  • Plan implementation is facilitated to assure that optimal patient progression-of-care is achieved.
  • Able to maintain flexible working hours to meet patient and family needs and to achieve plan and program outcomes.
  • Works well under pressure of time and shifting priorities.
  • Participates in initiatives to capture data on transition planning efficiency.
  • Performs other duties as required.