UnityPoint Health RN Cross Continuum Care Manager in Anamosa, Iowa
Description of Position:
Provide a “snapshot” or the principal purpose or focus of the position, consisting of no more than three to five sentences. This summary should provide enough information to differentiate the major function and activities of the position from those of other positions.
The care manager provides care management and population health services to patients within an assigned region. The primary target population to serve is the stratified high risk patient or patients with high vulnerability at times of transition between care settings. Priority will be given to patients in risk contracts.
Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care team across the continuum, and increasingly use data analytics to manage the health of populations to improve patient access to care and clinical outcomes.
Essential functions are the duties and responsibilities that are essential to the position (not a task list). o not include if less than 5% of work time is spent on this duty. Be specific without giving explicit instructions on how to perform the task. Do not include duties that are to be performed in the future. Duties should be action oriented and avoid vague or general statements.
% of Time
Longitudinal care planning
• Conducts in-depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the highest risk patients.
o Arranges for and participates, as appropriate, in a patients’ home environment assessment through an initial home visit.
o Holistic health care assessment includes: health risks, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
• Delegates care based on situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and holds care team accountable to complete delegated tasks.
• Develops shared care plan and document on the Common Care Plan to allow access by all care team members across the care continuum.
• Advance Care Planning:
o Connects patient and surrogate decision maker to ACP facilitation process.
o Ensure that Advance Care Planning documents are stored and available within the EHR.
• Performs outreach utilizing best practices to engage appropriate patients for care management.
• Reconcile discharge medication orders and medication orders by specialists and PCP.
• Ensure patient understanding of any medications to stop taking or initiate.
• Be clear to patient why medications were discontinued.
• Collaborate with MTM Team as needed.
• Anticipate and facilitate a Home Care visit to review and validate the medication plan as appropriate.
· Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners).
· Ensure that all members of the care team are aware of barriers, assets, and action plans.
· Access 2-1-1 for community resources.
· Supplement with internal database for community resources not available through 2-1-1.
Communication and coordination between care settings
• Working with the physician hospitalists/PCPs/specialists, leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
• Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families, and providers.
• Functions as a coordinator and manager of a defined health population across multiple care settings and for multiple physicians/health care providers or health plan counterparts.
• Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources:
o Coordinate referrals processes from PCP to Specialty.
o Provides oversight if patient transitions to SNF and monitor progress throughout the patient stay.
o Ensure post SNF transition plan is completed for TCM and follow up appointment is scheduled with PCP.
o Coordinates access to resources and supports to achieve the goals of care such as specialists, homecare, palliative, hospice and other community services.
o Initiates post transition phone calls to high risk / high vulnerability patients to assess self-management and to identify risk prior to their first appointment.
o Position Home Care to assist with evening and w/e ED cases to avoid admissions, similar to 3-day waiver and admission to SNF vs. IP.
• Participate in Readmission Root Cause Analysis.
• Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting.
o Initiate IDT/SWAT TEAM for patients with IP stay of 5 days or more.
• Identify transition needs when connecting back to PCP.
• Ensure that patient discharge appointments are consistent with predictive risk of readmission, i.e. Heat Map.
• Ensure consistent care management face-to-face or telephonic follow up for those declining Home Care.
· Assesses patient/family knowledge and confidence level of chronic disease self-management and refers to internal and external resources to meet identified gaps.
· Reinforces education regarding chronic disease self-management utilizing approved action plans, educational materials and best practice recommendations.
o Facilitates health and disease specific patient education utilizing Teachback.
o Utilizes and educates patient on Healthwise tools.
· Coordinates education regarding internal resources and other community support services to the healthcare team, i.e. wound care team, Diabetic Educators, Respiratory Therapy or PT.
· Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
o Encourages enrollment in patient portal and access to Healthwise Knowledgebase through portal.
· Identify high risk or soon-to-be high risk via EHR encounters or datasets to intervene as appropriate.
· Integrate patient registry, stratification, and other tools/reports to identify patients who may be appropriate for care management.
· Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for admission or readmission to a hospital setting, using a registry.
· Analyzes data to identify under/over utilization, improve resources consumption, promotes potential reduction in cost, and enhances quality of care consistent with organization strategic goals and objectives. Data includes but is not limited to: predictive analysis, risk stratification, cost-benefit analyses, financial analyses, clinical outcomes, utilization and practice patterns.
· Utilize dashboards or other reporting mechanisms to support performance improvement and outcome evaluation.
· Implement real time alerts to indicate when individuals are accessing the healthcare system or experiencing issues that could impact their health.
Basic UPH Performance Criteria
· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
· Demonstrates ability to meet business needs of department with regular, reliable attendance.
· Employee maintains current licenses and/or certifications required for the position.
· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
· Completes all annual education and competency requirements within the calendar year.
· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
Demonstration of UPH Values and Standards of Behaviors
Consistently demonstrates UnityPoint Health’s values in the performance of job duties and responsibilities
· Leverage the skills and abilities of each person to enable great teams.
· Collaborate across departments, facilities, business units and regions.
· Seek to understand and are open to diverse thoughts and perspectives.
Own The Moment:
· Connect with each person treating them with courtesy, compassion, empathy and respect
· Enthusiastically engage in our work.
· Accountable for our individual actions and our team performance.
· Responsible for solving problems regardless of the origin.
· Commit to the best outcomes and highest quality.
· Have a relentless focus on exceeding expectations.
· Believe in sharing our results, learning from our mistakes and celebrating our successes.
· Embrace and promote innovation and transformation.
· Create partnerships that improve care delivery in our communities.
· Have the courage to challenge the status quo.
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
Graduate of an accredited program for Registered Nurses.
Bachelors of Science in Nursing (BSN)
3 years clinical nursing experience
Previous clinical experience in a clinic or Home Care setting.
Previous experience with care coordination /care management and population health.
Current license in good standing to practice nursing in the state where care is provided.
Valid driver’s license when driving any vehicle for work-related reasons.
· Basic computer knowledge using email, web browser and documentation of care in an electronic health record.
· Knowledge of the healthcare system and resources available to patients.
· Strong clinical proficiency and ability to apply critical decision making in dynamic situations.
· Motivational Interviewing and applies Integrated Chronic Care Management skills.
· Cultural compliance
· Trauma informed care
· Ability to problem solve in complex situations.
· Strong interpersonal skills and ability to collaborate.
· Excellent communication skills-written and verbal.
· Strong self-motivation and ability to work independently, setting priorities to coordinate care plan efficiently.
· Proven leadership skills
· Ability to function effectively as a team leader in a team based environment.
· Patient focused
· Excellent customer service skills
· Strong organizational skills and ability to efficiently use tools and resources.
· Ability to perform multiple tasks
· Effective behavioral and educational strategies, including, but not limited to, motivational interviewing, teach-back method and self-management support
Use of usual and customary equipment used to perform essential functions of the position.
Work may require travel to other UPH or community facilities. May drive a UPH vehicle, rental or own vehicle.
Information about Jones Regional Medical Center - Anamosa, IA
Jones Regional Medical Center has been named 5th fastest growing hospital in the US by Modern Healthcare
· All private rooms
· Three major trauma rooms with an additional four exam rooms
· State-of-the-art equipment and lighting
· Easy navigation for patients to be evaluated and treated in the ED
· Radiology/laboratory services located next to ED for easy testing access
· 5500+ volume Monthly
· 24/7 RT, Lab, ER and Radiology
· Daytime offerings - Therapy, Wound, Social Services, Counseling, Rehabilitation
· Great place to have a rural quality of life but have access to larger cities (30-minutes to Cedar Rapids and 45-minutes to Iowa City)
Choose Jones County
Jones County, located in the heart of Eastern Iowa along Highway 151, is central to major U.S. markets. Within five hours of Chicago, Minneapolis, St. Louis, Madison, and Omaha with easy access to the crossroads of America, Interstates 80 and 35.
Living in Jones County
· Easy highway access to major shopping/entertainment in Cedar Rapids
· Just 45 minutes from Iowa City
· Growing trail system for walking and biking
· Museums including the National Motorcycle Museum and the Anamosa State Penitentiary Museum
· State and local parks for camping and recreation
· Two new aqua parks
· Numerous golf courses
· Home of the Jones County Fair the 3rd largest county fair in the state of Iowa.
Requisition ID: 2020-74150
Street: 1791 Hwy 64 E
Name: 1050 UnityPoint Health Jones Regional Medical Center
Name: Anamosa Family Medicine
FLSA Status: Exempt
Scheduled Hours/Shift: Monday-Friday Days