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Program Manager/Complex Care and Transition Management

Tufts Medical Center – Boston, MA

The Program Manager/Complex Care and Transition Manager is responsible for executing and maintaining the high risk chronic care programs and also acts as the Advanced Practice Provider managing the program and coordinating care for the patient over an episode of care, from as early as diagnosis across the continuum. The Program Manager will provide patient care within regulations in accordance to their licensure within the Commonwealth of MA. As an advanced practice Clinician, the Program Manager has received specialized training and education in the management of the acute care needs of the high risk complex care patients. By virtue of such preparation, the Program Manager is uniquely qualified to meet the responsibilities of the role which include, but are not limited to: Comprehensive assessment, diagnosis and treatment of common adult complex care diseases with acute exacerbations. Prescribing and performance of diagnostic and therapeutic interventions. Supervise protocols and insure compliance of studies. Development, evaluation and modifications of treatment plans as patient condition warrants. Review therapeutic orders for patients. Educate patient and families regarding clinical programs, disease progression, treatment, postoperative course and the patients role in recovery. Facilitate the complexity of care using the teach back methodology. Develops and maintains relationships between all members of the care team, administrative and clinical staff , producing high performing, patient focused teamwork. Screen patients for health literacy, depression and risk for readmission using a variety of evidence based tools. Implement a complex set of actions that address the psychosocial and lifestyle issues as well as their physical problems. Round in nursing homes on this group of patients. Coordinates the transition of care from one health care setting to another including inpatient, home health care, skilled nursing facility, rehabilitation facilities and other services as needed. Act as a transition liaison to the home care agency providing feedback and education on complex disease processes. Provide follow up to patients who are transitioned to the home setting. Provide education to clinicians on effective Transitions of Care.
Manages the program while practices in collaboration with the attending physician and other members of the multidisciplinary team to insure optimal patient outcomes. The Program Manager is accountable for the program and works in conjunction with the primary nurse, case manager and other members of the clinical team to provide patient and family centered care, providing psycho-emotional support, educational support and discharge planning that is individualized and comprehensive. Additionally, will be able to provide clinical consultation and participate in medical and nursing research. Will participate in continuing education, quality improvement initiatives, clinical outcome evaluation and monitoring. As well as has an understanding of or is willing to learn about ACO challenges, and high risk patient populations
Is accountable to develop and implement the Transition Management Program. Develops goals and measures of success to assist in priority setting, resource allocation and optimal team productivity resulting in excellent outcomes for patients. Oversee development of collaborative practice models in symptom management/ for complex diseases with acute care exacerbations across the continuum. Facilitate the development of interventions across disciplines which reflect complex care and high risk management. Is accountable for developing a collaborative model approach to community outreach/education in cooperation with the Director of Care Coordination, Medical Director and Physician Advisors. Is accountable to oversee and facilitate the implementation of evidenced-based interventions. Collaborate with the Nurse Directors for adult and pediatric populations and oversee the continuing education goals of the nursing and physician staff for the complex and high risk disease process and recidivism. Assist in collaborative research studies for focused diseases such as COPD, CHF that create multiple readmissions. As a formal member of the management team, collaborates with other members of the management team in developing, monitoring and evaluation QI projects on appropriate units using quality outcome indicators. Works with post-acute partners and care providers and facilitates, designs and implements best practices in complex and high risk care management. Oversees the Transition of Care in the identified high risk population.
Oversees a budget and resource allocation. Provides formal feedback to all members of the care team and support departments. Set goals and reports outcomes to designated hospital committees. Identifies and works with other leaders and members of the care team to remove barriers to transitioning patients effectively. Is a member of the management team
Clinical Practice:
The Program Manager applies advanced knowledge and experience to provide care to a caseload of patients assigned to the Program Manager, in collaboration with the attending physician. This care involves comprehensive assessment, diagnosis and treatment of common problems encountered throughout the disease process from initial diagnosis through the continuum of care including rounding at partner organizations such as SNF. The Program Manager provides comprehensive care management throughout the episode of care and across the continuum for high risk patients with specific attention to goals of care. Demonstrates the knowledge and skills necessary to provide care that is appropriate to the age of patients served in the clinical area. Provides education to the post acute providers. Rounds on patients in the post acute setting. Writes clear, comprehensive initial and follow up notes. Develops an expertise in ACO related knowledge. Develops goals of care for patients and families. Has a broad knowledge of resources available within the community. Communicates effectively with patients, families, providers. Plans effectively for any necessary home care, home infusion and follow-up. Initiates referrals and consultations with appropriate specialists as indicated. Facilitates family and team meetings as appropriate to patient care needs. Oversees the Transition of Care in the high risk population and plans effectively. Operationalizes Advanced Practice Provider role
The Program Manager consistently demonstrates skill and judgment necessary to direct the medical/nursing plan of care building collegial relationships among the team of his/her colleagues and peers to maximize patient care and outcomes. Delegates responsibilities to others with an understanding of their roles, knowledge and capabilities. Facilitates cooperative and collaborative relationships among the various disciplines and departments to ensure effective quality patient care delivery with the PCP and post-acute providers. Maintains a collaborative work relationship with peers and colleagues in order to create a positive work environment across the continuum. Serves as a leader and role model to all team members. Performs role in a consistently professional manner.
The Program Manager influences others by establishing a climate for optimal patient care, mutually supportive collegial relationships and professional development. Holds self-accountable for professional practice. Presents self in a calm and professional manner. Participates in performance improvement activities utilizing performance improvement principles to support and improve patient care. Attends and actively participates in staff meetings. Accepts responsibility for reading staff meeting minutes when not able to attend. Keeps current with literature regarding changing practices, interventions and research in patient care. Assumes responsibility for seeking out educational and professional opportunities for personal learning needs and growth. Assumes responsibility for meeting mandatory education requirements and unit specific education and competencies. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working groups achievement of goals, and to help foster a positive work environment. Performs other similar and related duties as required or directed.
Masters degree in Nursing or equivalent preferred. (MSN or MS) or Physician Assistant. 3-5 years acute care hospital advanced practice clinical experience. Advance Practice Nurse with specialty in geriatrics or family nurse practitioner or Physician Assistant with specialty in geriatrics or family practice. Management / Formal Leadership experience in health care preferred. An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements. Current Massachusetts Registered Nurse License to practice in expanded role (APRN). Or Physician Assistant. Bilingual skills preferred. Experience with leadership and management effective skills and styles. Experience with resource allocation and budget responsibilities. Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages, cultural patterns and care settings in each step of the care process. Ability to provide appropriate care for a caseload of patients according to practice guidelines and hospital policies, procedures and protocols. Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process. This includes: Knowledge of growth and development. Ability to interpret age specific data and response to care. Provide age specific communication. Prolonged, extensive, or considerable standing/walking. Lifts, positions, pushes and/or transfer patients and equipment. Considerable reaching, stooping, bending, kneeling, crouching. Frequent exposure to hazardous chemicals, sick patients, bodily substances, noise and possible exposure to radiation, lasers, electric shock, etc. Regularly exposed to the risk of blood borne diseases and other transmissible infections. Contact with patients under wide variety of circumstances. Subject to varying and Program Manager predictable situations. Handle emergency and crisis situations. May have contact with hazardous materials. Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

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