Disease Management Coordinator - Day

Duties and Responsibilities

• Identifies sepsis patients during their acute care stay and manages their care according to evidence based standards of care. Services as a liaison between the patients, families and healthcare team during hospitalization and the post-discharge period. Communicates to hospitalists and other hospital staff regarding abnormal findings in evaluation of patients and assesses readiness for discharge and risk for readmission. Administers follow up phone calls to all hospitalized Sepsis patients and addresses all problems that require attention to improve patient perception of care. Coordinates transitions of care to the appropriate post-acute services.
• Coordinates the sepsis program and initiatives locally, participates actively in implementation of changes recommended by the system CET.
• Participates in the development, maintenance, implementation and evaluation of written care protocols based on evidence including physician orders, clinical pathways for expected length of stay and clinical practice guidelines.
• Ensures data is collected, reviewed and analyzed monthly. Develops and implements action plans accordingly based on outcomes data. Collaborates with other disciplines using an integrated approach toward achieving optimal patient outcomes. Evaluates the impact of Social Determinants of Care on patient outcomes.
• Develops and implements the patient education process for all hospitalized Sepsis patients with emphasis on symptom recognition, risk factor modification and structured Care Coordination. Revises and monitors educational materials to ensure that they are coordinated, understandable and meet the program standards.
• Serves on/leads a Sepsis committee at the entity level and participates on the system CET. Prepares agenda and progress reports for the team that discusses readmission, length of stay and bundle compliance, identifies outcome measures that have not been met. Develops, implements and evaluates action plans for improvement with the team.
• Develops, coordinates and participates in community awareness programs about Sepsis Awareness and Management annually. Participates in Community based education for other outside groups to enhance patient care beyond the acute care facility.
• Role models critical thinking by demonstrating active and proactive problem solving.
• Coordinates staff education and maintains clinical competencies related to sepsis patient care.