Nurse Care Manager, Geriatrics

POSITION SUMMARY:

Performs a variety of high-level nursing case management services through the development and use of geriatric nursing practice standards. Activities include conducting a comprehensive geriatric nursing assessment, history and physical, developing and reassessing a plan of care which addresses the physical and psycho-social needs of the older adult and family, patient/family education and coordination of care and services across various sites of care.

The Geriatric Nurse Case Manager assists in the development, implementation, evaluation and revision of the case management model of care and program. Ensures that desired patient outcomes are achieved and that variances from established best practices are evaluated and addressed as necessary.

Position: Nurse Care Manager

Department: Geriatrics

Schedule: 40 Hours (Days)

ESSENTIAL RESPONSIBILITIES / DUTIES:

Patient Care

• Delivers direct patient care via home visits and/or hospital visits, as required.

• Utilizes telephone triage to evaluate patient care issues. Identifies actual and/or potential illness or change in condition which may impact the care plan. Makes recommendations to address identified problems.

• Provides proven methodologies and recommendations for successful implementation of the care plan. Implements a care plan which may include:

• care coordination to support delivery of medical, psychosocial care and associated care plans, activities of daily living, legal, financial management, etc.

• education regarding the health care delivery and reimbursement systems, prescription drug cost management, health & wellness programs, long term care insurance, health care proxy, asset and legal management, government, community agencies, public & private organizations, hiring through private entities, etc.

• advocacy to ensure the elders safety, physical, psycho-emotional legal & financial well-being, to support care-giving & quality of life goals, navigate the healthcare delivery system, obtain third party reimbursement for covered goods and services, etc.

• assessment and monitoring of care being delivered to the elder and provision of recommendations to the elder and/or their representative regarding the advisability of the need to modify care, the care plan, providers and/or vendors, as necessary and appropriate

• consultation and/or conferencing with the elder & their formal, informal caregivers, family, significant others, representatives to assess issues, consolidate information, coordinate planning and care delivery with and for the elder

• Ensure safe and appropriate transitions of care from one site to another using effective written and verbal communication skills and expert knowledge of community and long term care resources

• Participates in the development, implementation, evaluation, and revision of the nursing case management program in Geriatrics.

Patient Education & Support

• Communicates with patients, their representative and/or providers to effectively implement plans and provide appropriate expertise and information regarding ongoing eldercare care management issues and services.

• Facilitates problem solving and decision-making by providing guidance and support to the patient, family members, acute care providers and community health care provider around the prognosis and course of care in the acute care and community setting.

Program Management & Administration

• Collaborates with administration, physicians and other colleagues in Geriatrics and Medicine to develop, revise and update critical paths as well as support the development of DRG specific standards.

• Evaluates available financial variance and quality improvement data to determine the appropriate areas of focus for the nursing case management model and program. Assists in the development and monitoring of financial goals for targeted case managed patients. Assists in the planning and implementation of strategies to optimize reimbursement of services.

• Develops professional relationships with the community through effective networking and professional service which fosters a positive public image for the Geriatric Service and Boston Medical Center.

• Contributes to the education of nursing students and other health care disciplines with primary focus on geriatric nursing and case manager role.

• Expands geriatric practice base by utilizing, demonstrating, and conducting nursing research to maximize high quality, cost effective patient outcomes. Performs ongoing evaluation of case management program outcomes and identifies opportunities for improvement.

Professional Development

• Identifies own learning needs and assumes responsibility for maintaining current knowledge, competency, and expertise in area of specialty.

• Completes annual mandatory educational requirements, departmental/specialty competencies, and maintains appropriate credential status.

• Participates as a committee member and/or chair when requested by geriatric management team.

General:

• Conforms to hospital standards of performance and conduct, including…