Nurse Case Managers: Secret Weapon in Primary Care

Описание: Nurse Case Managers are the 'Secret Weapon' in primary care because they effectively manage hospitalized patients, their discharge and their follow-up with the PCP.

The job description for Acute Care Nurse Case Manager at ChenMed provides insight into the importance of primary care managing the hospitalizations of their patients.

Responsibilities of Acute Care Nurse Case Managers that work for Primary Care Practices:
1) Coordinate discharge planning with hospital case managers, insurance case managers, social work and facilities/services accepting the patients. Those facilities/services could be a skilled nursing facility (SNF), acute rehab facility, long-term acute care (LTAC) facility or home health agency.

2) Meet with the patient and family/caregiver in person daily. This means the nurse case manager travels to the hospital and sees the patient face-to-face.

3) Schedule a follow up appointment with the PCP for approximately 4 days after discharge. This appointment is made and communicated to the patient PRIOR to discharge.

4) Identify patients that are good candidates for and amenable to Community Case Management outside the hospital and Disease Management. The Case Manager then facilitates a 'warm handoff' to these other services.

Hospital Case Managers have in person interactions with the patient, but they are not accountable/responsible for continuity. Insurance Case Managers have accountability/responsibility for continuity, but they do not have in person interactions with the patient.

Only the Acute Care Nurse Case Manager from the Primary Care Practice has BOTH in person patient interactions AND accountability/responsibility for continuity. It is this combination that makes them more effective.

ChenMed Overview Video:    • Full-Risk Primary Care Described in 'The C...  

Sources:
https://careers.chenmed.com/us/en/job....

https://pubmed.ncbi.nlm.nih.gov/31145...

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