a Registered Nurse Case Manager and Social Work team in your emergency room
requires an organized and focused approach. Embedding your team allows for
improved visibility, accessibility and improved employee and patient
satisfaction. The care coordination team in the ED focused on 5 and 30 day
readmitted patients, patients that were high utilizers of services, in
addition patients who were already being followed by our teams with
individualized plans of care. Coordination is the Care in our ED Care
- Describe the role and functions of the ED Case Manager and how they contribute to initiating the care transition planning process, identification and initiation of potential referrals in preparation for return to the community and investigation of rationale for readmission of patients within thirty days of an acute care hospital discharge
- Identify how the ED Case Manager collaborates with the primary care physician and community coordinator utilizing technology to hand in and hand off using the electronic medical record (EMR) to increase accuracy of information required for continuation of care across the continuum.
- Present examples of how the ED Case Manager’s interventions have contributed to a reduction in overall length of stay, reduction in readmissions and enhanced the overall patient experience as evidenced by optimizing the patient’s quality of life and patient/family engagement in their health care decisions.