Care managers serve as resources to the clinical staff regarding the use of any clinical guidelines, and monitor the patient s plan of care, outcomes and key quality indicators. Additionally they promote the medical center s performance improvement initiatives. The social worker supports the psychosocial needs of the patient and collaborates with the medical and nursing staff to provide follow up for the patient s discharge needs. The social worker evaluates psychosocial needs and financial issues, making referrals to community agencies to assist patient and families as appropriate. The social worker intervenes as appropriate to facilitate adaptation regarding impact of hospitalization or lifestyle changes that may be needed.
Social workers address issues of physical abuse and neglect as per regulatory requirements.
The outcome manager is a master s prepared nurse with advanced clinical expertise. Outcome managers identify critical patient outcomes requiring measurement within a defined patient population. They collaborate with the care manager, physician and other team members to analyze system issues impacting patient care, and provide benchmark data to evaluate current performance. Outcome managers facilitate improvement of clinical, functional, satisfaction and financial outcomes using a performance improvement process. After making a systematic evaluation of a panel of indicators, information is reported to the appropriate parties to prioritize improvements.