Case Manager - Enhanced Care Team

Overview

Job Summary: 

Coordinates care of medically complex children, program implementation, and research-related activities. Works under the direct supervision of the program director of the Declan Donoghue Collaborative Care Program (DDCCP) and the pediatric palliative care/ complex care team, called the Pediatric Enhanced Care Program (PECP). Will implement, and monitor activities/operations of the DDCCP and participate in clinical and research activities of PECP. Facilitates the development, implementation, and tracking of research and quality improvement initiatives related to improving care to medically complex pediatric patients.

Major Accountabilities/Responsibilities: 

1. Adheres to the general hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships and team building.
   1. Following hospital policies and procedures.
   2. Following departmental policies and procedures.
   3. Contributing to the overall quality of services.
   4. Assuming responsibility for keeping informed about changes in policies and procedures.

• Practicing in accordance with hospital and nursing division’s philosophy, goals, and standards of care; North Carolina Board of Nursing; North Carolina Nursing Practice Act and other governing agencies.
• Demonstrating commitment to hospital and nursing division’s philosophy goals and standards of care.
• Respecting patient rights and confidentiality.

1. Protects self, coworkers, and facility by following appropriate policies and procedures to prevent the spread of blood-borne and/or airborne disease(s).
   1. Using work practice controls, engineering controls, and personal protective equipment appropriate for specific procedure(s).
   2. Demonstrating knowledge of infection control guidelines that are related to universal precautions and isolation procedures.

1. Identifies children and families who may benefit from DDCCP.

• Receives referral for the program from physicians
• Using eligibility criteria, determines eligibility for the program by reviewing child’s medical records. 
• Connects with families of eligible children, introduces the program, and gets permission for enrolling children in the program
• Obtains a detailed history from the parent of children enrolled in the program.
• Collects and reviews medical records of children enrolled in DDCCP 
• Using a template, creates a comprehensive clinical summary by reviewing the medical records

1. Ensures that plan for children enrolled in the DDCCP is written, managed, and evaluated.

• Participates, along with the DDCCP physician in interdisciplinary conferences for children enrolled in DDCCP.
• Creates meeting notes for children discussed in interdisciplinary conferences. 
• Works with DDCCP physician to implement the plan of care for each child enrolled in the program.
• Documents clinical activity in electronic medical records as appropriate.
• Remains a point of contact for families of children referred to DDCCP and serves as a liaison between families and providers.
• Communicates with other providers including primary-care physicians and specialist physicians about children enrolled in the program.
• Collaborates with members of the Pediatric Enhanced Care Program in the care of children enrolled in the program.
• Assists DDCCP physician in making referrals of children in DDCCP to other providers, and institutions as needed.

1. Develops appropriate reports to insure measurement of DDCCP activities.

• Collects data related to DDCCP operations in an existing clinical database
• Using an existing template, creates reports about DDCCP to hospital and physician leadership.

1. Leads and participates in appropriate initiatives related to DDCCP.

• Participates in formal and informal education programs related to dissemination of DDCCP.
• Participates in meetings and activities related to DDCCP.

1. Participates in research and quality improvement projects related to pediatric palliative and complex care.

• Participates as a nurse clinician in a large grant funded research project – creates clinical summaries, communicates with parent/caregiver of medically complex children, and works with the team’s complex care physician.
• Participates as a nurse clinician in other research activities and quality improvement projects as they come up in the future. 

8.         Participates in professional activities related to pediatric medically complex care.

• Maintains membership in professional organization related to specialty.
• Acts as a liaison to appropriate faculty, administration, staff, and select external organizations.