RN Transitional Care Coordinator Between Home Health and Hospice

DESCRIPTION:

The Transitional Care Coordinator facilitates admissions, transfers and discharges by providing supportive care and seamless transition to home based care, including home health, hospice, skilled nursing facilities, assisted living facilities, hospitals, etc.  The Transitional Care Coordinator assists the organization by assuring that the right care is provided at the right place and the right time.

JOB DUTIES:

·      Identify high risk home health patients and their appropriateness for hospice

·      Utilize EMR and analytics systems to determine patients to follow for hospice care

·      Attend home health case conference

·      Provide in home or facility evaluations for patient's appropriateness for hospice

·      Provide patient/family/caregiver education on hospice benefits

·      Admit patients to hospice services

To accomplish this goal of right care, right place and right time, the Transitional Care Coordinator uses established criteria to:

·       Evaluate the appropriateness of patients referred for home health or hospice services

·       Confirm the level of care most appropriate for the patient

·       Conduct an on-site assessment to facilitate safe and effective transition from inpatient to home health or hospice

·       Engage patients, family, caregivers as well as the inpatient care team to obtain appropriate information to support discharge to home health or hospice care

·       Holding continuity of care as a priority, the TCC communicates and coordinates with the inpatient care team supporting the patient including hospital case management and nursing,

patient’s physicians and other healthcare providers involved in the patient’s care at home.  The TCC will attend conferences as requested, facilitate orders, evaluate patient’s care (social

determinants of health, medical, pyscho-social and practical) needs, including medical eligibility of services, anticipated needs for equipment, medication and transportation

·       Serves as a clinical resource for patients, families, physicians, and facility staff for appropriate home placement, medication reconciliation, goals of care and identification of necessary support at home, as well as problem solving barriers or challenges related to the patient returning home

-       Manage PPCC Report in Knowledge Link and make referrals to appropriate service lines as needed

·       Partner with ALFs and SNFs to develop process of making referrals, going on co-visits to introduce patients to respective service lines, and engage in regular meetings to discuss potential patients/referrals

·       Engage in EPCC efforts and help agency partner in a meaningful way

·       Take action with individual patients to help reduce hospital readmissions and decrease ED utilization

·       Identify and communicate patients at high risk for hospitalization to care team

·       Maintains high risk tracker for readmission patients on active caseload, and help manage Cortex

·       Connects patient to appropriate resources to maintain their health at home including, but not limited to: arranging outpatient appointments, assuring appointment transportation needs

are met, confirm prescriptions can and have been filled, inquire about any barriers to health, etc.

·       Attends patient/family/staff conferences at hospital/SNF to assist with identification of patient needs

·       Facilitates timely initiation of care to home health or hospice

·       Utilizes reports and trends to support efforts and to understand clinical status and progress as it pertains to patient care

·       Assist patients in the process of navigating post-acute care

·       Assess, plan, implement, coordinate, monitor, and evaluate options and services with a primary goal of providing safe transitions from acute care to home for home health or hospice services

·       Integrate evidence-based clinical guidelines, preventative guidelines, protocols in development of transition plans that are patient-centered, promoting quality and efficiency in the

delivery of post-acute care

KNOWLEDGE:

·       Ability to utilize reports and trends to support efforts and to understand clinical status and progress as it pertains to patient care

·       Must have clinical knowledge and critical thinking ability to create a viable and effective patient care plan and identify barriers in services, effectively conduct verbal and/or written

report of patient care needs

·       Understanding home health and hospice services regulations, Title XXII, Medicare Conditions of Participation, reimbursement systems, home health and/or hospice accreditation requirements

·       Knowledgeable about disease processes and prognosis and how illness progresses clinically and functionally

·       Knowledgeable of how the range of home care services can help patients with a wide range of needs from post-surgical care to palliative care, to end of life care.

SKILLS:

·       Self-starter with a high degree of initiative, motivation, flexibility, energy and creativity

·       Ability to work as part of a team as well as form harmonious working relationships with internal and external customers

·       Excellent collaborative and problem-solving skills with customers and management

·       Excellent organizational skills

·       Must have excellent telephone, interpersonal and written communication skills

·       Strong commitment to teamwork and customer service, both internally and externally

·       Experience with Microsoft Office suite and electronic health record strongly desired

·       May be asked to work in field providing home care services as per changes in business needs and as skills and training allow

·       Must be able to develop an organized work plan in a high-volume environment with rapidly changing priorities

QUALIFICATIONS:

RN:

·       Minimum of 3 years of nursing experience required

·       Must have direct patient care experience within the last five years

·       One year experience in home health and/or hospice setting preferred within the last three years

·       Recent experience in acute-care hospital setting; knowledge of discharge planning/care management strongly preferred.