Case Manager Specializes

Description:

The Case Manager specializes in managing complex cases and ensuring comprehensive care plans are developed and implemented. This includes assessing eligibility for case management, leading a multidisciplinary team (MDT) including dieticians, health educators, physiotherapists, pharmacists, psychologists, and nurses to create comprehensive care plans, and developing personalized care plans in collaboration with healthcare professionals.

Key Responsibilities:

Assessment of eligibility of cases and their suitability for discussion by the MDT

Leading a multidisciplinary team (MDT) including dieticians, health educators, physiotherapists, pharmacists, psychologists, and nurses to create comprehensive care plans.

Chairing & preparing for MDT meetings - this includes reviewing patient records to assess care and treatment needs and determining which healthcare professionals should be part of the MDT meeting.

Assessing patient needs, identifying challenges, and developing personalized and holistic care plans in collaboration with the patient and the MDT

Optimizing the use of healthcare resources, including medical and community resources, to address the patient's specific needs

Assessment and mitigation of risks associated with complex cases, ensuring that patients receive timely and effective care.

Periodically monitoring and evaluating the patient's progress to ensure that care goals are met and make adjustments as needed.

Agreeing and supporting the managed discharge of patients from the case management service to their assigned FMP for ongoing management.

Providing ongoing advice and support to care coordinators and the patients assigned FMP to support the ongoing management of patients with complex health needs

Education:

Board certification or equivalent in Family Medicine