Case Managers are Masters prepared nurses with focus on disease management and patient education.
Case Managers ensure that patients are admitted and transitioned to the appropriate level of care, have an effective plan of care and are receiving prescribed treatment, and have an advocate for services and plans needed during and after their stay.
Clinical Need Identification and Assessment
- Provides clinical resource/consulting to assist in planning, implementing and coordinating patient care for selected patients across the continuum of care.
- Prioritizes patients for case management by identifying high risk, high utilization, frequent admission, readmission in 30 days and those with progressive chronic illnesses.
Clinical Goal Establishment
- Supports patients/families in understanding the goals, benefits and expected outcomes of treatment and services.
- Identifies, analyzes and evaluates trends in clinical outcomes to determine systems, personnel and process changes which result in improved patient outcomes and decreased readmissions.
Collaboration with Health Care Team
- Collaborates with patients/families and health care providers to achieve optimal patient outcomes.
- Communicates patients’ condition, needs and goals to other disciplines through patient care conferences.
Continuity of Care
- Follows up with all patients after discharged home.
- Follows up with patients readmitted with chronic health problems after discharge.
- Collaborates with Home Health, Skilled Nursing and O/P services on select patients.
Phone: (859) 301-5413
Hours: Monday – Friday: 8 a.m. – 4:30 p.m.