The Cardiac Case Manager Register Nurse (RN) works in collaboration with the patient, family, providers, clinical support team and office staff and within the team structure to ensure the provision of patient centered, cost effective and high-quality care to patients at risk for or diagnosed with cardiac conditions. This role involves both hands on and remote patient care activities as the nurse functions as a liaison among patients, families, Zufall providers and external partners.
Essential Functions, Duties and Responsibilities
- Patient assessment and Planning: Conducting comprehensive physical and psychosocial nursing assessments of patients to identify their needs, goals, preferences and barriers to care. Identify patients within the team with anticipated high-cost care, recent hospital admission requiring transition of care from hospital to home, high utilization of service, complex medical needs or those at high risk for complications or exacerbation of diseases such as hypertension, diabetes, coronary artery disease, congestive heart failure. Develop, implement and evaluate individualized care plans in collaboration with an interdisciplinary team of internal and external partners including but not limited to physicians, nutritionists, behavioral health. Assists providers with contacting patients to discuss results and additional procedures.
- Provides High Quality Care Consistent with the Scope of a Registered Nurse: In collaboration with the provider, provide skilled nursing services appropriate to the scope of a community health center including provision of wound care. Triage patients who present to the health center and who require evaluation for routine, acute, emergent or urgent care. Handle phone calls from patients seeking medical information and/or medical attention. Process medication refill requests.
- Care Coordination and Management: Facilitate the collaborative management of patient care across various settings including inpatient and outpatient hospitalizations. This includes scheduling appointments, coordinating follow-up care after hospitalization or ED visit, coordinating referrals to specialists and community resources and ensuring timely and efficient care delivery. Track completion of laboratory tests, diagnostic studies and referrals as directed by providers and in collaboration with clinical teams. Contact patients who are overdue for visits or who need short-term follow-up or additional studies. Assist patients with arrangements for transportation, translation, and other services to reduce barriers in attending appointments. Assist patients with completion of medical and prescription forms and referrals to other providers and agencies.
- Patient and Family Education: Educate patients and their families about heart conditions, treatment plans, medications, risk factor modification and self-management strategies to promote heart-healthy lifestyles and prevent hospital encounters. Educates patients about what, why, and how tests are being done. Instruct patients regarding preparation for all procedures.
- Advocacy and Communication: Serve as a patient advocate, ensuring their needs and preferences are considered throughout the care process. Maintain effective communication with all members of the healthcare team, patients and families to convey patient health status, treatment plans and progress.
- Monitoring and Evaluation: Monitor and track patients’ progress, adjusting the care plan as needed to help them reach their maximum medical improvement. This may include clinic visits as well as engagement in Self-Monitoring Blood Pressure and Remote Patient Monitoring programs.
- Documentation and Quality Improvement: Maintain accurate and complete patient records in the electronic medical record and participate in performance and quality improvement initiatives. Maintains active problem list in the electronic medical record.
- Performs other duties associated with an RN in a primary care clinic as needed and as assigned by CMO, SVP of Nursing and Clinical Operations and/or their designee
