The Care Coordinator RN for Home Care is responsible for coordinating home care services following discharge from one of Children's facilities, My Children's Clinic locations, or Community Provider. Functions include case management, discharge planning, clinical safety education to patient families, coordination of care with third party agencies, and in providing the communication link between the hospital and the patient's family. The Care Coordinator works closely with the interdisciplinary discharge team, physicians, and clinical resource management team to actively facilitate those functions associated with meeting patient needs after discharge from an acute episode of care, specialty clinic, or at the request of the patient's primary care physician.
Essential Duties and Responsibilities
- Coordination of Care: Complete case management services between the patient home and the hospital, Ambulatory clinic(s), physicians, and other service providers through written progress reports, in-home study visits, and case management initiatives. Will also assess the status of patient's plan of care and coordinate communication with necessary medical professionals to obtain new orders, prescriptions, labratory tests, etc. Assist patient families in accessing care and social services outside the home care department. Making referrals to community-based social service agencies when families need assistance and services beyond what Children's Medical Center offers. Help families maintain insurance coverage by providing information about state waiver programs available and general processes to maintain insurance coverage.
- Communication: Communicate patient needs to appropriate professional (i.e. social work, clinical pharmacist, clinical dietician); follow-up on communication. Communicate continually with patients and families, physicians, multidisciplinary team members and payers to facilitate coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum. Communicate with families to ensure understanding of payer guidelines and to arrange the best access to care covered by the payer. Maintain communication between the patient home and the hospital, Ambulatory clinic(s), physicians, and other service providers through written progress reports, home study visits, and case management initiatives.
- Clinical Management/Education: Collaborate with discharge planning team to establish treatment milestones and ensure home care is the Right Place, Right Time, Right Care setting for the patient. Educate the family on patient's status at time of discharge and prepare family to transition to home care servies. Review home care orders with family to ensure understanding and compliance to increase patient safety once in the home setting. Assess patient's home setting, available caregiver(s), and/or living arrangements to determine if physician's orders for treatment can be adhered to within the patient's home. Educate patient families about patient's condition, diagnoses, and home care treatments ordered at the bedside during discharge and then in the field once admitted to the Home Care Department. Participate in the development, implementation, evaluation and ongoing revision of the plan of care, clinical pathways and initiatives to improve quality, continuity and cost effectiveness.
- Process and Performance Improvement: Work collaboratively with other departments and services to define and study areas of inefficiency and participate in process improvement projects. Be involved in the development of strategies and plans to maximize the most appropriate use of services in assigned areas.
- Ability to meet physical and non-physical demands as outlined in the job description is an essential function of the job
- Two-year Associate's degree or equivalent experience required
- Four-year Bachelor's degree or equivalent experience preferred
- Graduate of accredited school of nursing required
Licenses & Certifications
- Registered Nurse, current license to practice professional nursing in the state of Texas required
- CPR required
- Current Texas Driver's License and automobile insurance required
- Minimum 3-5 years of related experience required
- Case Management, Home Health Care, Discharge Planning, Pediatrics preferred
Specific knowledge, skills, and abilties
- Physical and emotional health adequate for performance, which may require extended or flexible work hours, rapid assessment and response to patients, families and employees
- Ability to influence action; "care" to advocate for change; collaborate with and complement the clinical members of the patient's healthcare team; communication in an assertive yet responsible way
- Have the requisite clinical knowledge to enter into a partnership with key customers
- Analytical ability to effectively prioritize, assess, plan, coordinate and evaluate the care of patients and their families to achieve quality and cost effective outcomes
- Effective interpersonal skills with positive relationship building; effective written/verbal communication; ability to negotiate with interdisciplinary team members, physicians, families, payer sources and peers
- Knowledge of evolving healthcare systems, including but not limited to funding sources, third party reimbursement, contractual arrangements, managed care, continuum of care issues, disease management and clinical guidelines
- Evidence of self-direction, flexibility, adaptability, creativity, ability to prioritize efforts, ability to multi-task and effective time management
- Is knowledgeable of and acts in accordance with laws and procedures regarding patient confidentiality
- Experience with using personal computers
- Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly OR requires walking or standing to a significant degree.