Job Description:

GENERAL SUMMARY/ OVERVIEW STATEMENT:



The Transitional Care Manager (TCM) coordinates care for risk contract patients and helps guide them through the transition from one level of care to another. The coordination of care is accomplished through collaboration with the patient, family members, acute and post-acute interdisciplinary teams, and homecare. The goal is to optimize patient care transitions thereby reducing unnecessary utilization of services and decrease the risk of readmissions.


Through these coordination efforts the TCM works to improve patient care transitions by 1) assisting in setting appropriate patient and family expectations, 2) assuring an appropriate utilization of services, 3) assisting interdisciplinary teams in developing an appropriate discharge plan, and 4) communicate care needs with both primary care and community supports to decrease the likelihood of readmission.


For this position, the TCM will work with acute interdisciplinary team to determine the appropriate level of post-acute care for risk contact patients. The TCM will coordinate care for patients discharged to an associated skilled nursing facility (SNF) network. At the associated SNF, the TCM develops a relationship with SNF administrative and clinical staff to promote optimal and efficient patient care; TCM efforts will be coordinated through both onsite and telephonic rounding. By using established standard operating procedures, clinical decision support tools and length-of-stay (LOS) criteria, the TCM will work with the SNF to ensure the execution of efficient patient care plans within the approved LOS timeframe and connect patients back to Mass General Brigham providers upon discharge.


This position requires a broad knowledge of academic medical centers, community hospitals, post-acute services, clinical systems, electronic medical records (EMRs), and rehabilitative expertise. Additionally, a broad knowledge of clinical care, payer rules including but not limited to Medicare, and health services across the continuum of care are required.


The TCM will demonstrate careful professional and clinical judgement, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, flexibility, and the ability to multi-task. In addition to the above, the TCM will stay up to date in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent continuum of care topics.



PRINCIPAL DUTIES AND RESPONSIBILITIES



1. Conduct a comprehensive assessment of all acute hospital admissions for patients in the targeted population(s). Review of the patient's outpatient and inpatient electronic medical record. including but not limited to H&P, diagnosis and treatment plan, nursing, rehab (PT/OT/Speech) and case management notes.


2. Engage the acute hospital interdisciplinary team to confirm diagnosis, anticipated treatment plan, current and anticipated functional ability and provides clinical expertise in supporting formulation of the discharge disposition.


3. Identify the appropriate site of care and anticipated length of stay using MGB decision support tools and clinical judgment. The TCM will share the results of decision support tools with the acute interdisciplinary team as well as the patient and family for the purpose of discharge planning.


4. Supports a smooth transition and assure continuity of care as the patient moves through the continuum, ultimately back to the primary care setting.


5. Rounds on admitted patients as needed in the acute hospital, acute rehab, and post-acute facilities. Goal of weekly rounding is to maintain appropriate length of stay, support timely discharge planning, identify patient concerns related to care and discharge barriers.


6. Monitors the patient's progress to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost effective.


7. Identify patients with high utilization patterns and/or at high risk of readmission to the aligned RSOs Care Management Leadership Team so that additional surveillance and supportive measures can be implemented.


8. Serves as a clinical liaison between acute hospital case management department and MGB post-acute capacity program. This includes case finding of appropriate acute hospital patients, ongoing outreach to inpatient case management, daily engagement with MGB post-capacity leads and monitoring for successful completion of patient discharge.


9. Participates in program development including MGB post-capacity bed identification and patient monitoring. This work occurs at the RSO and MGB system level in identifying improvement opportunities in current workflows and designing new TCM programs.


10. Facilitate coordination across the continuum and assist with evaluating appropriate post-acute level of care with interdisciplinary team's (acute, post-acute, hospice and palliative care).


11. Evaluate risk contract patients referred for admission to an associated SNF. Establishes the anticipated LOS for patients at time of SNF admission, monitors and provides LOS guidance to the SNF facility.


12. Through onsite or telephonic rounding the TCM ensures appropriate implementation of patient care plans, patient progression, and helps navigate barriers to care for risk contract patients. For high-risk iCMP patients, collaborate with iCMP Care Coordinators.


13. Participates in patient and family meetings, as needed, to support the plan of care and discharge plan. Advocates for both patient and family.


14. Documents weekly rounds with SNF, care plan meetings and post-discharge assessments in EMR. Routes messages to providers and clinicians as a warm hand off or, to alert providers of potential issues during or upon patient discharge.


15. Participates in SNF Mini-Collaborative Meetings, individual SNF meetings, and TCM program management meetings. Includes contributing to discussions, reviewing data, and focus on improvement efforts per established priorities.


16. Along with program and hospital leadership, reviews TCM program clinical and financial outcomes. Provides recommendation and then executes program adjustments as indicated.



Qualifications

QUALIFICATIONS:

• Physical Therapist (PT), Physical Therapist Assistant (PTA), Occupational Therapist (OT), Speech-Language Pathologists (SLP).


• Graduate of an accredited program related to licensure is required. Bachelor's or master's degree preferred.


• Minimum 2+ years of experience of acute hospital or post-acute care setting required.


• Minimum of 2+ years of case management, utilization review and discharge planning experience preferred.


• Knowledge of Medicare regulations and guidelines at SNF preferred.


• Evidence of continued education and professional development.


• Experience with basic Microsoft Excel, PowerPoint, and Word preferred.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

• Strong assessment, critical thinking, and problem-solving skills.


• Strong interpersonal skills including excellent oral, written, and telephonic skills and abilities.


• Ability to work independently with minimal supervision.


• Ability to work in an interdisciplinary team-based environment.


• Goal oriented and accountable.


• Demonstrated organizational skills and an ability to manage routine work, triage and reset priorities as needed.


• Must be able to work in a fast-paced complex setting and demonstrate performance agility in a continuously changing environment.


• Demonstrates appropriate communication skills for the patient population served.


• Computer skills with the ability to quickly demonstrate competency in various software applications.


• Strong data analytic skills and interest in tying data to clinical outcomes.


• Flexibility with tasks and assignments as program needs dictate. Examples include assisting colleagues and providing coverage during vacations/unexpected illness/holiday time.

WORKING CONDITIONS:

• Flexibility to work and travel to a variety of locations as well as remotely.


• On-site settings include acute hospital and post-acute skilled nursing facility settings.


• Flexibility required to meet with patients, family, and providers in the acute hospital and post-acute facility required.


• Hours and work schedule will be flexible to meet the needs of patients, families, and facility staff but will generally follow a Monday-Friday eight-hour work schedule.

The above statement reflects the general duties considered necessary to describe the principal functions of the job and are not considered a detailed description of work requirements inherent in the position.



EEO Statement

Brigham and Women's Hospital is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Apply Now