Senior Case Coordinator-outpatients Care

Senior Case Coordinator-Outpatients Care**Job Code**:
30001707

**Basic Function**:
Facilitates and coordinates the transition of the high risk patient’s plan of care from one healthcare environment to another, or home, based on their need for continued care.

It includes a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual’s needs”

Acts as a facilitator with the patient, family and the health team by improving access to health care services and assisting the patient to navigate the healthcare system.

Empower the patient to problem-solve options of care and coordination of appointments, to promote self-management.

Leads the implementation of practice team based care, by providing leadership, guidance and collaboration between the patient and the multidisciplinary team.

**Scope**:
Incumbent has the responsibility to facilitate and coordinate the assessment, planning, implementation, intervention and evaluation of the options and services available to meet the patients’ healthcare needs across an episode or continuum of care. Facilitates patient wellness and autonomy through advocacy, assessment, planning, communicating, education, and resource management within a multidisciplinary team.

Actively works to eliminate barriers to the delivery of clinical services with the patient, family and healthcare team and monitors clinical resource utilization.

Creates a plan of care appropriate to the patients’ needs and resources. Based on the individual needs and values of the patient and in collaboration with all service providers the care manager connects patients with appropriate healthcare providers and human services and care settings, whilst ensuring that the care provided is safe, effective, patient centered, timely, efficient and equitable.

Involved with quality improvement programs and measures to improve patient care, outcomes and coordination of services.

**Principal Contacts**:
The Case Manager interacts with all disciplines and individuals in the multidisciplinary team.

**Principal Duties**:

- Oversees and coordinates the patient's plan of care and monitors multidisciplinary patient care activities to develop appropriate care delivery strategies for identified patients, and make recommendations as required. Ensures that interventions are aligned with the medical management initiatives.
- Collaborates with members of the healthcare team to ensure the multidisciplinary plan of care is developed, followed, and modified as needed
- Assisting patients in setting specific, measurable, achievable, realistic and time-bound (SMART) goals for self-management, teaching them how to do self-management tasks, and reporting abnormal findings to their physician team.
- Be an advocate for the patient to encourage involvement with decision making with own health care provider.
- Use evidence based guidelines in daily practice of case management for patients.
- Support patients with health behavior change, measuring a patient’s willingness to be involved with a plan of care and treatment goals.
- Plan, teach and supervise patients with physical care measures, social/emotional care, to promote improvement in their health care management.
- Direct involvement with medication reconciliation for patients’ in collaboration with the Clinical Pharmacist.
- Shared communication between the Primary Care physician and other services to improve coordination of care.
- Participates in inpatient management if patient known to service is admitted
- Develop and use of Adapted Orders to change treatment regimens or pre visit planning to ensure investigations available for physician appointment
- Provide Complex Patient Teaching.
- Providing follow up contact with patients/ care givers as indicated to ensure compliance with recommendations-medications, lab/x-ray, specialists visits, Primary Care visits, dietician
- Providing telephone advice per protocol, handling urgent calls and emergent calls
- Developing a list of medical supply and community resources available to patients and maintaining collegial relationship with the entities used most frequently.
- Provides leadership that incorporates the nursing philosophy, mission, and vision, goals and objectives and standards of the organization in order to facilitate the delivery of high quality patient care.
- Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, quality and efficient.
- Promotes a positive work environment conducive to productive, collegial relations among all members of the health care team.
- Ensures section maintains disaster and fire preparedness.
- Promotes the involvement of nursing in the Community Health Awareness programs.
- Supports and monitors the quality Improvement/Risk management interventions in the section and evaluates outcomes of patient care.
- Particip