Health Promotion and Disease Prevention (HPDP) Case Manager (CM): The incumbent will develop and execute appropriate multi-disciplinary case management activities in collaboration with the Associate Director, Patient Care Service (ADPCS), Chief of Staff (COS), Health Promotion and Disease Prevention Nurse Manager (HPDP NM), RN Disease Manager (DM), Group Practice Manager (GPM), Patient Aligned Care Teams (PACT), and others as needed in support of HPDP population health needs. The incumbent will develop an annual Case Management (CM) plan for inclusion in the inclusion in the HPDP strategic plan in collaboration with all stakeholders, (e.g., COS, ADPCS, HPDP NM, GPM, PACT). Uses available data sources (e.g., Strategic Analytics for Improvement and Learning (SAIL), VHA Support Service Center (VSSC), etc.) to identify, assess, and prioritize the needs of the patient population. Uses data-driven processes to prospectively and retrospectively identify indicators of ineffective or inefficient delivery of care including, but not limited to, high-cost, high-volume, or problem-prone diagnoses, procedures, and services, and high utilization rates for services (e.g., pharmacy, Urgent/Emergency Care, Ambulatory Care Sensitive Conditions (ACSC), and outpatient visits). Make recommendations for cost containment or process improvements. Collaborates with the ADPCS, COS, GPM, PACT, Patient Educator, and Associate COS's for Education in the development and implementation of patient education for patient self-care management; provides CM education/training for all clinicians to included but not limited to; Case Management, complete health and psychosocial assessment demographic information, medical history, vocational information, health status, current/projected resource utilization, psychological status, community/social support systems, health risk assessment, home/environment assessment, and patient's health goals, care coordination processes (e.g., discharge planning, continuum of care, and Clinical Practice Guidelines (CPG)). Provides CM assistance/guidance to PACT or other service for coordination of care for complicated/complex high-risk patients. Will ensure a warm handoff (person-to-person verbal communication providing continuity of care and a seamless transfer of information) of patients in transition to other levels or places of care by providing pertinent information to the gaining health care provider (e.g., patient self-management status); documents warm handoff in Computerized Patient Record System (CPRS). Documents CM-related care provided using the face-to-face, Clinical Video Telehealth (CVT), telephonic, or secure message (SM) encounters in CPRS. Will Code encounters appropriately using International Classification of Diseases (ICD), Evaluation and Management (E&M), and DM-specific Healthcare Common Procedure Coding System (HCPCS) codes. Encounters and or historical documentation will be completed and signed within 72 hours. Participates in comprehensive multidisciplinary patient care planning meetings (Care Coordination Review Team (CCRT)) as member of the HPDP team. Ensures the comprehensive patient care plan includes, but is not limited to, objectives, goals, and actions designed to meet the assessed needs for healthcare, safety, attainment of agreed by the patient/family and the multidisciplinary care team of the patient's health goals and ensures agreement is documented in Computerized Patient Record System (CPRS). Collaborates with RN Disease Manager, HPDP PM and stakeholders (e.g., ADPCS, COS, HPDP PM, GPM, PACT) in the development of an annual Utilization Management (UM) plan for high cost, high volume, and high patient utilizers for inclusion into the HPDP strategic plan. As member of the HPDP team, will collaborate in the performance of UM data analysis using available data resources (e.g., VISTA, CPRS, ACSC, SAIL, VSSC) and reports data as needed or instructed. Will report negative trends and identify quality of care issues requiring immediate attention. Will participate as HPDP team member in the evaluation of clinical practice patterns and trends and provides feedback to clinical. Conducts nursing peer reviews as assigned. Is a member of the HPDP Program Committee and actively participates in care coordination meetings/committees as assigned. Other duties as assigned. Work Schedule: Monday-Friday, 07:30am-04:00pm or 08:00am-04:30pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.