Medical Home Network

Manager

• Engage with patients during hospitalization focusing on reasons for hospitalization, reinforcing care management plan of care, updating information for the Medical Home Care Management team, plan of care post-discharge, and goal setting
• Complete assessments as appropriate, such as risk screenings, initiate Care Plan, TOC Bundle, and others as needed
• Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified
• Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning
• Assess patient readiness for change and work with care team to ensure patients discharge to proper services and identify/address barriers to assure efficient and complete transitions of care
• Participate in care team meetings and Integrated Care Team collaboration as necessary
• Develop relationships with staff in inpatient hospitals (general acute and behavioral health) and Medical Home Care Management staff; gather and share medical home and discharge planning information between hospital and medical home
• Work with the patient and medical home to secure timely follow-up appointments
• Communicate and document activities and outcomes to the patient’s medical home care manager regularly
• Assist in leading transitions of care trainings for care management staff
• Participate in quality improvement initiatives as identified
• Other duties as assigned

Care Manager, Transitions of Care