Hospital Case Management Role Responsibilities Case Management Process 1. Patient identification and selection: Focuses on identifying patients who would benefit from case management services. 2. Assessment and problem/opportunity identification. 3. Development of the care coordination plan: Develops a plan and prioritizes the patient's needs, as well as, determines the type of services and resources that are available to address the desired outcomes. 4. Implementation and care coordination plan. Facilitates the plan in collaboration with others. 5. Evaluation of the plan and follow-up. Periodically evaluates the plan and revises as needed. Discharge Planning 1. Identifies patients who may require post discharge services utilizing high risk screening criteria, referrals, or other available resources. 1. Completes an assessment of patient discharge planning needs based upon medical condition including previous history, functional status, psychosocial support, living situation, and previous post discharge or homecare services. 2. Includes patient and/or family and caregivers in the discharge planning process through verbal and written communication. 3. Facilitates safe, effective, and efficient discharge plans in collaboration with the patient, the family, caregivers, the attending and/or primary care physician, nursing staff, other appropriate clinical staff, third party payers, and/or community-based care coordinators or other appropriate outside agencies. 4. Conducts ongoing assessment of the patient's health status, ensuring the patient is appropriate for the services/care provided and revising the post-acute plan as needed. 5. Ensures the implementation of the discharge plan including making facility/agency referrals and determining availability of services. 6. Ensures whenever possible, third-party payer approval of services needed for post-acute care. 7. Acts as consultant to physicians and hospital staff regarding resources, regulations, and reimbursement. 8. Documents the assessment, plan, and ongoing notes as part of the health record according to hospital and departmental policy. 9. Completes the case management sections of necessary discharge paperwork if applicable. 10. Facilitates the paperwork sent to post discharge service providers with the goal of improving transitions of care. 11. Participates in the planning, implementation, monitoring, and follow-up of patients either prior to or following hospital episode of care in collaboration with external healthcare providers including Primary Care Physicians, as well as, community-based organization. Utilization Management 1. Provides expert guidance to the medical, nursing, and rehab staff, as well as, other Hospital departments regarding Hospital criteria, insurance regulations, care coordination efforts, and discharge planning activities. 2. Performs admission and concurrent utilization management using Hospital approved criteria as a guide for determination of appropriate level of care. 3. Completes accurate insurance utilization reviews and obtains third party payer approval of services needed for post-hospital care as needed. 4. Identifies utilization management issues; 5. Identifies and intervenes in service delays and inappropriate utilization of health care resources 6. Identifies patients at high risk for readmission and influences enhanced care practices and/or other interventions. 7. Identifies methods to reduce readmissions, 8. Participates in medical/utilization management activities for those patients whose health plan has delegated medical management to the Newton Wellesley Physician Hospital Organization. 9. Refers appropriate cases to the Physician Advisor, Physician Hospital Organizati