The Accountable Care Nurse (ACM) is responsible for proactively coordinating care and assisting with transitioning medically complex patients from the hospital to the community. The RN ACM works collaboratively with physicians and nurses in the hospital, primary care providers, and care managers in the ambulatory setting, home care, patients, their families, and is the responsible lead for the multidisciplinary transitions care management team assuring the team follows all One City Health program protocols. The RN ACM will assess patients to identify risks impeding adherence to medical/behavioral health treatment plans, coordinate with the hospital care teams during the patient's stay. They will provide disease self-management education and assist patients and caregivers with understanding care plans. They will assure follow-up with patients and caregivers in the community for 30 days post discharge to help reduce unnecessary hospital readmission and ED visits.
Assess patients for potential program admission through attendance at rounds/team meetings, referrals from medical practitioners, lists of identified high risk patients eligible for care transitions program.
Meet eligible patients on the unit soon after admission to initiate engagement; collaborate with hospital health care team to review patient status and ensure processes are in place for patient to have a safe, timely discharge to the desired setting.
Completes assessment of patient to determine what care, services and follow up are needed to ensure a safe discharge and transition from hospital to home (or other setting).Obtains medical/ behavioral health appointments as indicated. Documents initial assessment and care plan interventions in patient centered care plan.
Conducts a post discharge phone call within 2 business days of hospital discharge to ensure patient obtained all prescriptions, understands discharge instructions, is following discharge plan, and ensures ordered services are in place (or pt. has been contacted about them).
Assists in obtaining urgent care appointments if symptoms require, educates patient on disease self- management and when to call PCP/Care Transitions Team versus activating 911.
In conjunction with the patient and caregiver develops a plan to respond to disease exacerbation/decompensation when patient transitions to the community.
Reviews plan with patient to attend follow up appointment with PCP (and specialist for disease(s) which impact patient's health) and other community needs as indicated.
Updates care plan with patient/caregiver(s) as indicated and ensures care plan is shared with PCP prior to first visit.
Coordinates with community service providers including home health care agency field nurse. Assess for additional needs not previously identified (example if unsafe housing or caregiver relationship has evolved, lack of food, heat or other unsafe/unsanitary conditions, missed appointments that require referrals).
Continues to monitor patient progress, assigns responsibility to the social worker and community liaison as patient becomes medically/psychiatrically stable. Coordinates with other team members to delegate follow up calls referrals and home visits. Conduct daily huddles with team members to communicate vital information and ensure patients' ongoing care needs are met.
Document all encounters in GSI and updates care plan, reviews records as indicated for quality and completeness of documentation.
Carries appropriate caseload as per One City Health Guidelines.
Directs other team members such as Community Liaison and Social worker in the assignment of patient responsibilities.
Performs other duties to promote patient care management as assigned.