Description
Ensures patient receives post-acute care from high value network providers, and follow up appointments are scheduled.
The Patient Care Navigator (PCN) readies the patient for discharge and ensures that all patients are provided transition to the best setting for post-acute care based on their specific needs. The PCN educates patients/families on the post-acute care plan and expectation after discharge, helps them preference their best facility or service for care after discharge, and keeps a relationship with the patient/family after discharge.
Within 24 hours of admission
· Receive and review patient post-acute care plan
· Meet with patient/family
Throughout patient stay:
· Educate patient/family on post-acute care plan, expectations of post-discharge realities
· Coordinate discharge teaching with care team
· Regularly connect with the patient’s interdisciplinary care team
· Communicate discharge plans with Care Navigation Center
· Review financial respoinsibility with patient/family
· Tailor care to patient clinical and psychosocial needs
· Post-Acute facility/service and physician preferencing based on patient/family needs and goals; educates patient/family on CMS quality measures
· Coordinates activities to ensure patient’s appeal rights under Notification of Hospital Discharge Appeal Rights
Upon discharge:
· Confirm discharge orders
· Discuss follow-up plan with family
· Appointment/follow-up scheduling
· Ensure DC papaerwork (prescriptions/DME/referral forms/signatures) ready for discharge
After discharge:
· Patient follow-up call within 24 hours, continued contact based on evidence based decision tools
· Medication adherence
Escalation to clinical team and post discharge issues for appropriate intervention and resolution
