The RN Case Manager will oversee care management and care coordination for patients identified by the care team physician with having four or more active chronic diseases, is identified as a high risk patient (poor outcome for any social, economic, compliance or medical reason), or is a patient on warfarin for anticoagulation. This will include developing and monitoring health promotion, disease management and care coordination processes, and support primary clinical teams with these efforts. The position will involve patient triage.
1. Actively manages and maintains regular contact with patients in the high risk case load. The frequency of contact will vary according to the patient's situation at the time and is determined in consultation with the physician. Areas to be addressed include compliance with the medical regimen, effectiveness of new treatments, follow up of home monitoring such as glucose in diabetics, and weights in patients with CHF, adjustment of diabetic medication, dietary compliance, exercise compliance and other lifestyle interventions.
2. Perform initial intake nursing evaluation on all new patients who take medications for chronic disease.
3. Perform pre-visit chart review on the high risk case load patients. This should identify labs to be done, prescriptions to be refilled, consultations that may be due and ascertain that all appropriate preventive care is being performed.
4. Utilize after visit summary review with patients whenever appropriate
5. Contact all hospitalized patients within 72 hours of discharge to ensure that the discharge plan is being followed, troubleshoot unforeseen problems, and help expedite follow up appointments.
6. Coordinate outreach processes for the patients with care opportunities identified by clinical teams – can include visits, consults, lab, x-ray, ancillary services, immunizations, etc.
7. Report regularly to the patient's physician for input, guidance, and adjustment of the clinical plan.
8. Manage by protocol warfarin dosing in all anticoagulation patients who take warfarin.
9. Educate patients about self-management tasks they can undertake to gain greater control of their health status and develop workflows to involve the patients in activities to improve their health. (Patient Engagement).
10. Assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
11. Participate in the process of incorporating evidenced based diagnosis and treatment guidelines into the care processes in the practice.
12. Coordinate management of care opportunity reports and process for addressing these care opportunities. Identify best practices among the clinical teams and communicate to all.
1. State Licensure as a Registered Nurse
2. 5 years of outpatient clinical experience in the area of chronic care
3. EMR Experience.
4. Must complete and pass the Proficiency Assessment delivered at the conclusion of the onboarding program.
About SSM Health Dean Clinic-
Based in Madison, Wis., Dean Clinic consists of a network of more than 60 clinics in south-central Wisconsin. Our more than 500 physicians provide primary, specialty and tertiary care in the clinics as well as eye care through our Davis Duehr Dean locations. Dean Clinic also offers urgent care services and operates outpatient surgery centers. Dean Clinic joined SSM Health in 2013.