Acute Transition Care Management RN/Registered Nurse Forsyth County

LOCATION:
Remote - must live in or near Forsyth County, North Carolina.
Must have the ability to travel in or near Vaya's region.

GENERAL STATEMENT OF JOB

Acute Transition Care Manager, Registered Nurse (ATCM, RN) reports to the Acute Transition Care Management, Registered Nurse Manager (ATCM, RN Manager) and is responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients ("members") who are receiving care in an inpatient community hospital or emergency department for physical health reasons to ensure that these individuals receive appropriate transitional care and services.
ATCM, RN works with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/ developmental disability ("I/DD"), traumatic brain injury ("TBI"), physical health, pharmacy, long-term services and supports ("LTSS") and unmet health-related resource needs networks, while ensuring existing or new care team members are informed of transition plan.
This position supports and may provide clinical transition planning assistance to community hospitals and tracks individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization.
The ATCM RN promotes effective cross-organization communication and maintains collaborative relationships within the organization to achieve division objectives.
The ATCM, RN maintains skills in care management, care coordination, disease management and patient transitional care management.
This position may work with internal staff, hospital staff, members, guardians/family members, community stakeholders and others as appropriate to meet member's transitional needs.
Performs other duties as assigned.
The ATCM, RN also utilizes licensed clinical knowledge and skills to assess needs, inform transition planning development, provide clinical consultation, and offer recommendations for appropriate care.

As further described below, essential job functions of the ATCM, RN includes, but may not be limited to:

• Utilization of and proficiency with Vaya's Care Management software platform/ administrative health record ("AHR")
• Outreach and engagement
• Compliance with HIPAA (Health Insurance Portability and Accountability) requirements, including Authorization for Release of Information ("ROI") practices
• Performing Health Risk Assessments (HRA):
  a comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas to ensure a whole person approach to care
• Adherence to Medication List and Continuity of Care processes
• Participation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care management
• Transitional Care Management, Diversion from institutional placement

This position is required to meet NC (North Carolina) Residency requirements as defined by the NC Department of Health and Human Services ("NCDHHS" or "Department").

• In some circumstances, to best meet member, provider and stakeholder needs, this position working hours to begin before Vaya's 8:
30am hours of operation

ESSENTIAL JOB FUNCTIONS

Acute Assessment, Care & Transition Planning & Interdisciplinary Care Team:

Conduct or ensure all elements of transitional care management are implemented for members during physical health inpatient stay to include, but are not limited to the following:

• Proactively identify Vaya members and ensure assignment to TCM or CC to manage the transition;
• Meets with members to conduct transitional care management and gather information on their overall health, including behavioral health, developmental, medical, and social needs;
• Provide transition planning for members not already engaged in Tailored Care Management;
• Use clinical skills and expertise to review clinical assessments and transition plans conducted by providers to ensure all areas of the member's transitional care needs are addressed;
• Work in an integrated care team including, but not limited to, doctors and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved;
• Link members to appropriate follow-up services including physical health, pharmacy, behavioral health and other identified social determinate of health needs;
• Ensure that the care plan includes a transition plan developed by care team or, if necessary, by the ATCM, RN to meet needs and to access care for the individual;
• Convene key providers and others to address needs of the individual including participation in in-person or telephonic treatment team meetings, while the member is still in the facility;
• Support and assists with education and referral to prevention and population health management programs
• Coordinate Diversion efforts for members at risk of requiring care in an institutional setting
• Visit, or make best effort to contact, the member during their stay in hospital and be, or be sure a member of the care team, is present on the day of discharge when possible;
• Identify gaps in services and supports, intervenes to ensure that the member receives and can access appropriate care;
• Measure results of intervention and treatment, including reduction a high-risk events and inappropriate service utilization;
• Ensure that services are coordinated across the Vaya Health system and with other systems, including primary care, Opportunities for Health services and supports, social determinants of health, nursing facilities and/or specialist;
• Ensure development of a written discharge plan through a person-centered planning process in which the member has a primary role and which is based on the principle of self-determination.
  Include the discharge plan in the member's care plan;
• Provide clinical transition planning assistance to local community hospitals, and coordinates with care team, and tracks those discharged from local hospitals to ensure timely follow up with aftercare services to prevent further hospitalizations;
• Assist the member in obtaining needed medication/prescriptions prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence;
• Develop or begin development of a ninety (90) day post-discharge transition plan prior to discharge from physical health inpatient settings, in consultation with the member, facility staff and the member's care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community;
• Ensure that any barriers preventing the member from being discharged and transitioning into the chosen integrated setting are recorded in the member's Car.