Patient Care Facilitator

Care Coordination

Leads efforts with the interdisciplinary care team to develop, implement, and evaluate an individualized plan of care to achieve optimal patient outcomes for each assigned patient.

Ensures that patient safety risks are assessed, and prevention measures are implemented and communicated to all members of the interdisciplinary care team.

Routinely reviews the plan of care with the patient and family to assist them in understanding goals of care and movement toward these goals.

Affirms timely communication of patient’s response to care, clinical data, and diagnostic test results to appropriate physicians, care team members, and patient/family.

Makes referrals to other disciplines as necessary to meet patient care needs (social work, therapy, etc.).

Conducts daily “huddles” with care team to ensure plan of care is being implemented and progress toward established goals is being achieved.

Provides timely communication of changes in the plan of care to all care team members and patient/family.

Learns patient/family care conferences on appropriate patients based on LOS and complexity of care.

Collaborates with physicians and Utilization Management staff to ensure resource utilization remains within covered benefits.

Monitors each patient’s treatment plan for testing/treatment not related to current hospitalization and interfaces with physician to identify alternatives to address needs.

Discharge Planning

Writes plan for post-discharge services and collaborates with Discharge Specialist to ensure services are scheduled with appropriate entities, which could include home health, home infusion, hospice care, durable medical equipment, medical supplies, and outpatient services.

Ensures appropriate discharge education is provided to patient/family/caregiver.

Interacts with patient/family/caregiver to ensure discharge plan meets patient needs.

Collaborates with Discharge Specialist to update patient/family and interdisciplinary care team of changes in the discharge plan.

Quality Management

Identifies problems and/or opportunities for improvement in clinical outcomes, patient safety, and/or resource utilization.

Leads efforts to resolve ongoing patient and/or systems problems.

Participates in department goal setting, program development, clinical and system process improvement, and achievement of desired department outcomes.

Implements strategies to reduce resource utilization and length of stay for assigned patients.

Leadership

Participates in local and national professional nursing organizations.

Identifies areas for professional growth and demonstrates ongoing activities necessary to meet professional goals and changing needs of organization.

Promotes implementation of evidence-based nursing practice.