Transitional Care Coordinator - HomeCare

Transitional Care Coordinator - HomeCare Hartford HealthCare at Home - 3.6 Torrington, CT Job Details Full-time 21 hours ago Qualifications Stakeholder relationship building

Full Job Description Location Detail:

65 Commercial Blvd Torrington (10413)

Shift Detail:

Business Development - Field Sales position in our Torrington Location covering the entire Northwest portion of the state. Requires some weekends to represent the company for sales events. Work in collaboration with hospital case managers and or social workers, skilled nursing facilities, Assisted living facilities, Independent Living Facilities, home care agencies, and physicians to provide education to customers, patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patient's transition across the post-acute care continuum. Serves as a bridge between the healthcare team and the patient and/or caregivers, as well as helps to reduce facility re-admissions. Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team. Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referrals and building new clinical initiatives. In general, most of the time will be spent in the following activities: Strives to reach / exceed corporate assigned admission goals for all service lines Building relationships and trust across the continuum Marketing HHCAH service lines for system and non-system partners Identifying patients at risk during transition to home (or SNF) using standard tools of assessment. Review demographic and clinical information and ensuring accuracy of information in the transition from one setting to another. Chart review completed upon notification of the referral is as follows: Review key information from EPIC / hospital chart (e.g. patient demographics, history and physical exams, comorbidities, other hospital services received such as therapy and ongoing needs) Identify DME/supplies and company with contact information and document for HHC@H team Identify critical/high risk medications/labs/care that need next day start of care and document for HHC@H team Identify if patient has, CCCI, Agency on Aging, WCAA, CHCPE, ICP, Pro Health and or ACO services and document for HHC@H team Communicate information that is essential in formulating an effective plan of care to HHC@H staff in conjunction with supportive documentation Monitor all current/new patients while at hospital / SNF & ALF and alert HHC@H team when start of care will be needed Document current/new HHC@H patients that transition from acute setting to SNF with co-TCC following up with SNF to capture that patient once short-term rehab is completed Assist transitioning complex case / high risk patients home in collaboration with Care Coordination / hospital team / patient / family Conducting an "at the bedside" meeting with the patient and/or caregiver and following the patient during the post-discharge transitional phase.

During Bedside visit:

Patient visual assessment, education on disease process, clinical review, social review may be done. Following up with the patient to ensure that the patient is following transitional plans and goals of care. Bedside visit may include but is not limited to: Determine the patients language interpretation needs Identify skilled need and homebound status Identify location the patient will be receiving home care services Assessing patients health literacy and using teach back method as learning tool Identify primary caregiver with contact information, including alternate contact information Identify high risk patients and / or barriers to discharge Confirm patient has transportation to appointments Engage in attainable goals with holistic and sustainable plan to avoid readmissions Identify Physician most appropriate to sign home care orders and review importance of MD/Specialist follow up appointments Identify

POA, HCR, COP, COE

prior to or during visit. (Legal representative) Qualifications Required experience: Minimum of 1 year recent homecare and or Sales/Marketing experience

Preferred:

Licensure, Certification, Registration R.N or LPN with an active license to practice in the State of Connecticut may be required for specific Transitional Care Coordinator positions in the hospital setting.

Preferred Education:

Education Associates Degree/ Bachelor's Degree