Steward Health Care System LPN-Care Management-40 hrs/week-Day Shift-Weekends Required in Brighton, Massachusetts
At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion, and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.
We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.
In support of this, we commit ourselves to the following values:
If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.
Position Summary: The LPN Discharge Transition Coordinator contributes to the safe, timely discharge of patients from the Medical Center to appropriate post-acute care services. The LPN Discharge Transition Coordinator will be assigned to selected areas of the Medical Center on a rotating basis to assist in the development of discharge plans through coordinating communication with patients, families and clinical team members and post-acute care providers. They will be responsible for initiating, facilitating and coordinating referrals to post-acute care providers. They will perform discharge planning assessments based upon department staffing and coverage needs. The LPN TC will coordinate with the Social Workers assigned to the unit to prioritize tasks daily. As this is an evolving position, duties and responsibilities may vary based on specific assignments.
Recent experience in acute care setting involved with clinical activities and/or a managed care environment working in case management
Recent experience in a case management or related role preferred
Excellent computer skills including managing work against performance metrics and reporting on key indicators important to the department
Education and Competencies:
Graduate of accredited School of Practical Nursing
Strong computer skills with knowledge and proficiency with Microsoft Word, Excel
Demonstrated experience with managing against clinical and performance goals
Demonstrated skills in working collaboratively with physicians, managers, and other team members
Demonstrated skills in organizing and time management to complete assignments accurately and on time
Current licensure in Massachusetts as a Licensed Practical Nurse
Evidence of continued professional development
Scope of Authority:
Collaborate with Social Worker (SW) Care Coordinator on the floor who will be responsible for the development and execution of patient discharge plans.
Coordinate with the SW Care Coordinators to prioritize work and/or support complex discharge plans.
Work with Care Management Director to develop educational needs and identify strategies to accomplish objectives of the Department.
Given this job position is a new position; additional tasks may be added as the position is further developed.
Discharge Planning and Execution:
Screen and assess patients and families as assigned to determine clinical, psycho-social, and financial issues that impact discharge planning.
Provide patients and families with options regarding their discharge plan early in the hospital stay. Facilitate/Participate in patient/family care conferences to review resources, provide family education, and identify post-hospital needs.
Contribute to the development of discharge plans focused on resources necessary to achieve patient care goals. Reassess plan throughout patient’s hospital stay and revise as necessary.
Evaluate patient and family needs to identify barriers to discharge and develop strategies to eliminate or reduce them.
Coordinate and monitor discharge planning activities for an assigned patient population and provide support to the Social Worker CC and administrative staff managing the discharge process.
Communicate with the discharge team and the PCPs/Hospitalists towards creating an individualized discharge plan for high-risk patients, as needed, to ensure appropriate level of services are scheduled for the patient.
Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health Agencies, physicians, and other staff to ensure all post-acute clinical information is provided. Information to be provided on a timely basis to not delay discharge.
Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate.
Provide patient education and family teaching, on an as needed basis.
Act as an advocate for the patient.
Promote nursing care within legal, ethical, and professional standards.
Act as liaison to managed care case managers for evaluating outpatient resource management needs for of patients when appropriate.
Rotate to other units of the Hospital including the ED as directed by the Care Coordinator Manager and the schedule for the Department. Rotate and cover weekends and holidays, as directed by the CM Director. For all areas of the Hospital, perform all the functions stated in job description.
Review with the CM Director management reports that provide Department performance metrics of Department and personal performance. Performance metrics to include but not limited to timely completion of discharge planning assessments and closing of referrals.
Review own personal performance and provide feedback in writing on how to improve performance on a routine basis.
Support the Care Management Director in maintaining the financial and clinical outcomes of the Care Management Department.
Support the Steward physician network by coordinating with the Steward ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community/ambulatory care coordinators are put in place.
Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
Identify service needs, systems issues, and opportunities for improvement for the Department
Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
Report deviations in quality care to the Director of Care Management.
Assist with the development of clinical guidelines, as needed.
Attend Care Management staff meetings
Complete all paperwork required for regulations.
LPN Discharge Transition Coordinator will be evaluated based upon clinical and financial criteria where they influence the outcome. Some of these criteria include –but not limited to:
Discharge plan to achieve positive clinical and financial outcomes for assigned patients
Lengths of stay
Timely patient discharges – goal is 11:00am for patient discharge
Full, accurate use of Allscripts, Meditech.
Demonstrated collaboration with Social Worker CM, physicians, residents, and RNs on floor. This evaluation will be measured with feedback for other members of the care team
Information for staff evaluations will be collected by Department and will be made available for performance reviews. Selected data will be provided by the LPN Discharge Transition Coordinator. Other data will be provided by CM Director , Social Workers.