Case Manager

Overview

The Case Manager provides comprehensive care management services to ALP and ACF residents. This includes, but is not limited to psychosocial evaluation, evaluations for admission, resident’s rights and advocacy, group work and family counseling as appropriate. The Case Manager is a key member of the interdisciplinary care team and is responsible for ensuring maximum quality of life for an assigned group of residents or clients.

Job Duties Specific to This Position:
Resident/Client Care

• Responsible for the ongoing care and support for residents in their caseload.
• Provides care interventions for residents and families in time of crisis, deteriorating health (physical and mental), dealing with disabilities, deterioration of independence and end of life, etc.
• Educates resident and family/care giver on advanced directives. Facilitates completion of advanced directives with family.
• Serves as advocate for resident/client in absence of caregiver/family or if resident is unable to do so.
• Coordinates identified resources and services for timely discharge, involving the resident and family. Ensures complete, accurate and timely documentation.
• Coordinates and facilitates resident and family meetings. Ensures communication with family members not in attendance.
• Provides effective orientation for new residents and families or caregivers. Reviews residents’ rights.
• Explains housing and program rules, regulations and procedures. Assists residents/families in completing required forms and in gathering necessary documentation.
• Assesses resident financial situation, referring to Finance Department as necessary, i.e. Medicaid application. Provides financial counseling as required.
• Evaluates the resident and family's adjustment to placement and environment. Provides interventions as required.
• Works with residents to identify their unmet needs.
• Maintains communication with outside providers and Loretto interdisciplinary team members to discuss progress and coordinates resident care efforts.
• Participates in rounding and other team meetings.
• Ensures communication processes that facilitate and support the successful maintenance of the residents. Ensures effective communications between direct care staff and residents and families.
• Arranges or provides referrals to services in areas of income, maintenance, health, mental health, and social services.
• Assists the EL Supervisor to ensure that follow up medical appointments are scheduled and that transportation is coordinated.
• Participates in the intake process as well as in case conferences with other agencies.
• Follows residents in hospital or rehabilitation facilities to ensure timely decisions regarding return to facility or to assist in discharge planning. Reevaluates residents for readmission.
• Follows up on information as required documented on the 24-hour report.
• Assures resident/client has appropriate clothing and toiletries to support hygiene objectives.
• Assures that residents in need of personal belongings, furniture, etc. are given support to obtain items.
• Reviews Aide care plans and schedules for all residents to support the provision of services and to make sure all needs are being addressed.
• Informs program RN of any discrepancies and/or changes to care plan and/or functional condition of residents to facilitate revision to care plans as necessary.
• Assists with data collection for all incident reports.
• Monitors incident reports for indications of care plan modifications and required interventions. Initiate actions as appropriate.
• Responsible for discharge planning including persistent efforts.
• Ensures that communications from other service providers are followed-up on when necessary.
• Ensures that the implementation, follow up and discharge of required ancillary services (such as Home Care, PT, etc.) have required documentation.
• Reviews and follows up on initial medical evaluation (DOH-4449) and pre-admission Interview for relevant care management information. Provide appropriate resolutions and documentation.
• Reviews annual and/or other follow up medical evaluations (DOH-4449) and provider updates for stated care management needs.
• Reviews and responds as required to any care management issue noted on 24-hour report.
• Ensures communications from other providers are followed-up on as necessary.
• Handles filing as required after documents have been reviewed by all appropriate managers.
• Maintains all mandated forms and charts per policy and procedure.
• Maintains current advance directives by updating quarterly, upon return from hospital, and prn.
• Submits care manager reports as required.
• Maintains accurate and complete care plans (initially, quarterly, annually, significant change).
• Maintains accurate, complete and timely documentation on new admissions, including social history, advance directive tracking sheet, family information, funeral arrangements, and progress notes.
• Maintains current family contact information by updating annually and when necessary.
• Counsels and instructs…