Suvida Healthcare is a neighborhood-centric, multidisciplinary primary care program built to address the physical, behavioral, social, and cultural needs of the underserved Medicare-eligible Hispanic population. Multigenerational in design, Suvidas differentiated approach will enable us to deliver on the quadruple aim, improving health outcomes as well as consumer and employee experience while lowering total cost of care. Suvida will thoughtfully cultivate an empathetic and service-centric environment, positioning us not only as a best-in class health care provider, but also as the provider of choice for our patients, their families, and the community at large.
We are an empowered primary care team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and the neighborhoods we serve.
To improve the quality of life for underserved people and those that care for them in neighborhoods across America.
The Nurse Care Manager will work with Suvida Healthcares multidisciplinary care team to provide high quality care for our high-risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations. This nurse will need to plan effectively in order to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient utilization of resources.
The Nurse Care Manager will implement Suvidas care pathways for patients with chronic conditions. They will also oversee transitions of care for patients to ensure safe transitions from acute to post-acute care, by coordinating timely and cost-effective care. The Nurse Care Manager will oversee highly complex and resource intense patients within their assigned care team.
They will collaborate with all providers, care team, patients, caregivers, payers, community resources, and external providers to promote quality of care.
Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers
Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans
Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility
Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers
Coordinates/facilitates patient care progression throughout the continuum.
Works collaboratively and maintains active communication with providers, nursing, and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge.
Consults with appropriate disciplines/departments as required to expedite care and facilitate discharge.
Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness
Communicates with and the patient and family regarding the discharge planning process to minimize any anxiety or apprehension and optimize patient outcomes and patient satisfaction
Knowledgeable of the Four Elements of the Coleman Model
Coordinates post-discharge needs with providers, such as equipment, medication and supplies
Schedules patient for follow up with PCP or specialist within 7 days of discharge
Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge
Reviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions
Coordinates discharge needs with patients, caregivers, and acute facility providers and ensures the arrangements with post-acute care providers and care team members are completed
Communicates discharge plan with patient and their family and all involved in the most efficient manner
Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives
Works with clinical team to establish care programs to help prevent readmissions and hospitalizations.
Collaborates with the multidisciplinary care team to ensure awareness of discharges needing specific care and coordination
Obtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries
Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors the patients progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
Identifies at-risk populations using approved screening tool and follows established reporting procedures.
Refers cases and issues to clinical leadership team and follows up as indicated.
Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
Communicate with patients and caregivers to assess needs and develop an individualized continuing care plan in collaboration with providers.
Collaborates and communicates with multidisciplinary care team and with transitions of care team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation
Ensures/maintains plan consensus from patient/family and care team
Refers appropriate cases for social work intervention as needed
Collaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies.
Actively participates in clinical performance improvement activities
Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data
Collects, analyzes, and addresses variances from the plan of care with multidisciplinary care team
Documents assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency
Other duties as assigned