RN Geriatric Care Manager

Job Description

Job Description

COMMUNITY HEALTH :

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties.

ABOUT THE ROLE :

The Nurse Care Manager will provide complex, care support and coordination for Geriatric patients that possess a wide range of medical complexities. This role involves managing patients who have positive screenings and require specific resources tailored to their needs. Additionally, the nurse is responsible for conducting comprehensive assessments and delivering necessary treatments during annual wellness exams. The goal is to ensure that each patient receives personalized care that addresses their unique health challenges and promotes their overall well-being.

The Care Manager will collaborate with patients identified through risk stratification, with a focus on emergency room and inpatient discharge follow-ups, inpatient readmissions, transitions of care, with a focus on geriatric patient healthcare needs. The Care Manager supports patients, their families, and care team members to manage medical conditions and co-occurring behavioral health, psychological, and social determinants of health concerns throughout the healthcare system. The Care Manager supports patients transitioning between healthcare practitioners, inpatient, and outpatient venues (including visiting nurses) and home settings. This includes community resources and services that support a patient through one level of care to another.

FUNCTIONS OF THE POSITION :

• Provides follow-up care to all identified patients based on their level of complexity and challenges with social determinants of healt h.
• Specializes in geriatrics, assisting elderly patients with challenges through individualized programs and ongoing care management.
• Provides support in comprehensive health assessments to identify patient needs and develop personalized care plans to support Providers in providing thorough and comprehensive exams.
• Assists Provider in follow up care once Health Assessments have been completed.
• Collaborates with specialty practices to ensure patients receive the necessary specialized care and support.
• Provides guidance and support for patients who have positive screenings, ensuring they receive appropriate follow-up care and resources.
• Collaborates and coordinates patient care, identifying any potential post-discharge concerns or barriers that have been identified.
• Provides transitional care to risk-stratified patients post-discharge from either outpatient or inpatient venues.
• Ensures that hospital-discharged patients have adequate education and knowledge of their medication list through medication reconciliation.
• Determines the frequency of telephone encounters based on specific patient needs.
• Identifies barriers to care (including social determinants of health) for care-managed patients and reaches out to appropriate resources based on patient needs.
• Determines at any time that a patient requires a face-to-face visit.
• Utilizes an identified schedule to follow up with their patients.
• Follows up with all identified care-managed hospital discharge patients who do not keep their appointments and provides additional follow-up based on patient needs.
• Identifies a complex or high-risk patient, irrespective of whether the patient has been hospitalized.
• Reviews patient lists to identify patients requiring care management services.
• Works with Visiting Nurses, SASH, Council on Aging, VCCI, RMH, various support groups, and any other member of the healthcare team or community stakeholders, as necessary.
• Assists patients identified as needing intense care / chronic disease management with individualized programs on an ongoing basis.
• Develops a panel of patients who need care management services by creating a care plan to improve their health outcomes (e.g., CCM, ACO, CM).
• Actively participates and collaborates in managing patients that require home health visits.
• Assists with transitions of care for patients moving to or from home, hospital, rehab, or other facilities.
• Completes designated self-chart audits.
• Complies with the required expectations for consistent documentation of care management services provided.
• Specializes in geriatrics, assisting elderly patients with challenges through individualized programs and ongoing care management.
• Once geriatric patients are stabilized, screenings are completed and current resources are managed, a soft hand-off will be provided to the designated Primary care Manager in addition to the Care Manager that may support them in their behavioral health needs.

SKILLS REQUIRED FOR SUCCESS :

HOW WE SUPPORT YOU :

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