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The Case Manager is a member of the health care team and collaborates to enhance the delivery of patient care services along the continuum of care. The Case Manager meets patient’s needs efficiently and expeditiously by continuously improving the patient’s experience, helping to ensure the institutional standards of high-quality patient care, reducing cost and ensuring reimbursement. Through broad knowledge of clinical care and systems management, the case manager evaluates, predicts, and facilitates the trajectory of patient care. A working knowledge of palliative care and hospice care is highly desirable due to the specialized needs of the service.
In collaboration with the Palliative Care Service, Emergency Department, and other members of the health care team, this role is responsible for supporting a select population of patients with serious illness and complex care needs and facilitating their transition to the most appropriate care setting, which could be an MGH palliative care observation or inpatient acute care unit admission, skilled nursing facility, hospice, or home with services.
• Documents in the medical record as appropriate, as part of the Interdisciplinary team in accordance with the MGH Case Management Documentation standards
• Utilize a translator when appropriate and incorporate awareness of patient’s cultural needs that may impact the plan of care.
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