TITLE: Quality Process Coordinator/Discharge Planner

DEPARTMENT: Quality and Patient Satisfaction

GENERAL SUMMARY AND SCOPE

Performs concurrent and retrospective multi-disciplinary review of patient care. Uses comprehensive quality review criteria to collect data pertaining to the appropriateness of care. Compiles and organizes data into meaningful reports for evaluation. Identifies opportunities for improvement and coordinates interdisciplinary intervention for planned change. Assists and acts as a resource for assigned functions to facilitate quality activities. Promotes development and enhancement of total quality systems.

Under the supervision of the Director, this position is responsible for initial and ongoing discharge planning throughout the acute care continuum, including but not limited to coordination of care through the facilitation of a safe and appropriate discharge plan to the post-acute environment.  This process is supported by current research and evidence-based practice. The Case Manager identifies potential risk management and utilization issues and reports findings per departmental protocol. Works closely with the Social Worker as appropriate in the identification of discharge and transition needs and is ultimately responsible for the coordination of discharge planning activities. This is accomplished by working collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes.

ACE OF HEARTS PLEDGE

The employee will demonstrate the ACE of Hearts Pledge, which involves being an accountable and collaborative team member; treating patients, families, and co-workers with dignity and respect; and ensuring that empathy and compassion are the basis for interactions with all those served.

ESSENTIAL TASKS, DUTIES, AND RESPONSIBILITIES

Possesses knowledge and remains current with interdisciplinary standards of care to effectively review patient care, compliance with evidence-based best practices, prioritize quality of care interventions, and facilitate immediate action when necessary.

Conducts “real time”/concurrent and retrospective assessments of processes and outcomes for assigned populations and communicates within the interdisciplinary team and provides direct service, as needed, to assure delivery of best practices.

Demonstrates the ability to assist with the development of criteria-based evaluation tools; identifies opportunities to improve patient care, assures appropriate reporting and follow through with physicians, nursing, and ancillary services.

Aggregates data and provides reports that are timely, pertinent, reliable, and accurate to report positive and negative findings. Abstracts direct patient data as needed.

Collaborates with Directors and caregivers of assigned care areas regarding development and refinement of care processes as indicated through monitoring.

Institutes immediate feedback to personnel regarding systems/process/quality deficiencies, as needed.

Coordinates the flow of findings to facilitate peer evaluation.

Demonstrates responsibility for the management of the quality information contained in the assigned database, monitoring functions and registries including inputs, validation of data, and required reporting.

Exercises ingenuity, judgment, and problem-solving techniques in the absence of established guidelines and precedents and consistently demonstrates an ability to assess a situation from a variety of perspectives, consider several alternatives, and chooses an appropriate course of action.

Demonstrates responsibility through responsiveness to others and competent follow-up on matters requiring additional attention; contacts appropriate personnel as required, following appropriate channels of communication.

Demonstrates a consistent level of performance; avoids periods of extremely high activity and very low activity; maintains progress on special projects; regularly demonstrates initiatives and flexibility in scheduling.

Conduct comprehensive discharge planning assessments within 1 business day of admission or as required.

Conduct readmission risk stratification and follow-up care as appropriate

Collaborate with interdisciplinary care teams to develop individualized discharge plans based on medical, psychosocial, and functional needs.

Facilitate communication between the patient, family, physicians, nursing, social work, and post-acute care providers.

Arrange and coordinate post-discharge services, including but not limited to:
  - Skilled nursing facility (SNF) placement
  - Home health services
  - Rehabilitation services
  - Durable medical equipment (DME)
  - Transportation
  - Follow-up medical appointments

Post hospitalization phone calls and intervention s appropriate

Provide patients and caregivers education regarding discharge plan

Document all discharge planning activities in the electronic medical record (EMR) in accordance with hospital policy.

Identify and address barriers to discharge in a timely manner.

Participate interdisciplinary rounds as per hospital policy.

Maintain current knowledge of community resources, insurance guidelines, Medicare/Medicaid, and managed care regulations.

Promote patient safety and readmission reduction through proactive discharge planning and education.

Communicates with nursing and medical staff in assessing the psychosocial needs of the patient to monitor and oversee the discharge plan.

Maintains current working knowledge of HFAP, COBRA, EMTALA, OSHA, CMS and other regulatory standards.

Maintains current, accurate documentation in the patient's medical record.

Maintains current and accurate data collection related to the quality of the delivery of care of the department.

Works with the social worker as appropriate in assigning tasks and responsibilities in the discharge planning process

Maintains a working knowledge of and update community resources in areas of practice.

Participates in reporting abuse, neglect or exploitation suspected prior to hospitalization as indicated by hospital protocol. Report findings to the appropriate agency.

Assures all high risk and/or complex patients have an interim plan of discharge established prior to discharge from our facility.

Proposes alternative placement and/or treatment options as appropriate to facilitate and ensure a cost-efficient plan of care and quality outcomes.

Collects appropriate avoidable delays and other data as directed.

 

OTHER TASKS, DUTIES AND RESPONSIBILITIES

Participates in department performance improvement activities as assigned and attends required training.

Demonstrates service excellence and ACE.

Performs other duties, as assigned, to support the Quality and Patient Satisfaction Department.

Supervises and assists with selection and evaluation of clinical support personnel

Responsible for referring patients with special financial needs and/or requirements to the appropriate finance personnel.

Contacts attending physician to clarify patient’s medical information and discharge plans and identify potential needs.

Collaborates with the Director of Case Management and refers to Physician Advisor on difficult cases.

Assumes all other tasks or responsibilities as assigned by the Director

Participates in educational programs as appropriate and available.

Attends and participates in monthly department staff meetings.

Identifies clinical or system/process breakdowns and improvement opportunities and documents according to the PI plan.

Intervenes and recommends appropriate referral to resolve system/clinical barriers to patient progression, collaborating with other disciplines as appropriate.

Assures compliance with regulatory standards of care both at the state and federal level.

Assesses all patients or potential risk management and quality issues through appropriate intervention or referral.

Abstracts, tracks and trends data related to resource utilization, avoidable tests/procedures, case management interventions, etc. as directed.

Initiates referrals to Ethics Committee, Physician Advisor, QA, Risk Management or legal services as appropriate.

Assists Social Worker in the initiation of advanced directives or provides resources as needed to educate patient/family.

Demonstrates professional accountability through supporting patient’s rights, informed consent and advanced directives.

Identifies patients/families in need of grief or crisis intervention and makes referrals as indicated.

Completes mandatory legal reporting processes.

Reinforces education with patient/family on plan of care, discharge instructions, follow up, and expected outcomes.

Completes mandatory legal reporting processes.

Reinforces education with patient/family on plan of care, discharge instructions, follow up, and expected outcomes.

Educates patients and families regarding community resources, access to routine health care, and health maintenance.

Participates in department performance improvement activities as assigned and attends required training.

 

KNOWLEDGE, SKILLS & ABILITIES

RN-BSN Preferred

Background/quality experience preferred.

Ability to work in a fast-paced environment.

Demonstrated ability to work with constant attention to detail and accuracy. Demonstrated ability to work closely and cooperatively with others; educate effectively and influence appropriate actions to effect positive change.

Ability to utilize personal computer and various software applications for the management of information.

Ability to maintain data and records in a neat and orderly manner.

Ability to understand instructions and effectively communicate in both written and oral form.

Punctual attendance at assigned work location is required.

Ability to work in a safe and efficient manner and maintain an accident free work place, including ability to demonstrate a working knowledge of Medical Center emergency codes.

Ability to comply with OSHA regulations and CDC standard and transmission-based precaution recommendations and to utilize proper personal protective equipment.

Ability to comply with provisions of applicable S.D.S. forms.

Successful completion of a 90-day probationary period

License must be active and valid in the State of Ohio.

Three to five years’ experience in an acute care hospital setting.

Experience with case management process.

Certification in a field related to Case Management preferred.

Punctual attendance at assigned work location is required.

Ability to work in a safe and efficient manner and maintain an accident free work place,

including ability to demonstrate a working knowledge of emergency codes.

Ability to comply with OSHA regulations and CDC standard and transmission-based precaution recommendations and to utilize proper personal protective equipment.

Ability to comply with provisions of applicable S.D.S. forms.

Successful completion of a 90-day probationary period.

 

CORPORATE COMPLIANCE

The team member understands expectations and acts to assure full compliance with all Medical Center policies and procedures as well as all federal, state, and local regulations. This requirement includes reporting as directed by policy non-compliance with policies, procedures, and regulations.

HIPAA/CONFIDENTIALITY STATEMENT

All workforce members are required to understand and adhere to the standards and policies of Firelands Regional Medical Center which relate to the use and disclosure and the security of personal health information (PHI). All workforce members will participate in relevant training and will seek guidance and support when necessary to address HIPAA-related issues and resolve questions about the standards and policies. This requirement includes performance to assure the highest standards of confidentiality for employee and patient records and sensitive work-related information. The team member understands the principles of confidentiality associated with Medical Center employee and patient records and performs within the highest standards of care to ensure these records remain confidential at all times.