The Transitions Coach is key to ensuring safe and successful transfers in the movement of patients (“members”) across the care continuum. The Transitions Coach serves as the facilitator of interdisciplinary collaboration across a member’s transition by working with the professional staff in a care setting (e.g., hospital), ConcertoHealth’s multidisciplinary team of case managers, disease managers, registered dieticians, physicians, pharmacists, Utilization Management Staff, the member’s Interdisciplinary Care Team (ICT), if applicable, and the member and/or the member’s family/caregiver(s).
The primary roles of the Transition Coach are to ensure a safe transition to the least restrictive and most inclusive setting of the member’s choice and to encourage self-management and direct communication between the member and their providers. The Transition Coach engages in interventions to mitigate the risk of inpatient readmissions, Emergency Room visits and/or movement to an institutional setting. The Transition Coach will connect with members in person, over the phone and at the provider’s office to better understand their pre- and post-transition needs.
The Transition of Care Coach must be willing to work a flex schedule to support the business needs of reaching members post discharge within 24-48 hours. Position may be remote, or office based.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Member Planning and Monitoring Activities:
- Review daily census for new member assignments (e.g., admissions, observations and discharges) and monitor the transition status of existing members.
- Monitor inpatient census and utilization management reports to determine which members require inpatient visits and which members require post-discharge follow-up.
- Collect and review member information prior to the inpatient assessment or post-discharge assessment.
- Outreach to inpatient facilities to obtain the member’s disposition.
- Within two business days of notification of an inpatient admission, attempt to meet with the member and/or the member’s family/caregiver(s) in the inpatient setting or telephonically to assess their knowledge of the clinical condition(s) and provide education and self-management support.
- Educate the member and/or the member’s family/caregiver(s) about ConcertoHealth’s Transition of Care Program and provide contact information should any problems arise during the inpatient stay or following discharge.
- Identify barriers and gaps in care needs and readmission risks factors prior to discharge using ConcertoHealth’s assessment tools.
- Identify the member’s current living conditions and preferences prior to discharge.
- Evaluate the member’s level of independence or the types of supports they have by assessing the member’s family/caregiver(s)status.
- Coordinate all aspects of the member’s transition from the inpatient facility to the community/home in collaboration with the hospital discharge planner or case manager and ConcertoHealth’s Utilization Management Department.
- Keep the member and/or the member’s family/caregiver(s) informed of health status changes, expected treatments/procedures and anticipated discharge plans during the inpatient stay.
- Serve as the facilitator of interdisciplinary collaboration, advocate and resource for the member, and build effective relationships through trust, respect and communication.
- Refer the member to other disciplines as necessary for additional services and assessments (e.g., home and community-based waiver, disease management), as needed for members that require it.
- Conduct post inpatient follow-up (telephonic) with members within 24-48 hours of the notification of a member’s discharge up until 30 days of discharge and then transition the case back to the member’s Care Coordinator/Care Manager (if applicable).
- Conduct a series of required post-discharge assessments using ConcertoHealth’s assessment tools to review the member’s discharge plan, assess for any discharge needs, assist with coordinating and scheduling follow-up care, perform medication reconciliation and discuss medication management and educate on warning signs and red flags and how to report them.
- Review the member’s discharge plan post transition to assess for any additional needs and to ensure the member fully understands the plan and is educated on the importance of following the discharge plan.
- Perform medication reconciliation of pre-inpatient and inpatient medications to develop a complete medication list.
- Discuss medication management.
- Schedule follow-up appointments and ensure they are performed.
- Arrange transportation to and from appointments as necessary.
- Arrange for DME or other medical supplies, home and community-based services, personal care services and community-based services and supports as necessary.
- Perform assessment for personal care services if the member appears to require assistance with Activities of Daily Living (ADLs) and/or Instrumental Activities of Daily Living (IADLS), as needed for members who require it.
- Educate the member to recognize symptoms that indicate their condition is worsening and how to appropriately respond.
- Coordinate services with the member’s PCP and other providers.
- Assess progress toward meeting self-management goals.
Compliance-Related Care Management Activities:
- Perform a Health Risk Assessment (HRA) using Company assessment tools within the required contractual timeframes.
- Schedule and facilitate Interdisciplinary Care Team (ICT) meetings and maintain written documentation of all meetings.
- In collaboration with the member and/or the member’s family/caregiver(s) and ICT (if applicable), develop/update a person-centered care plan within the required contractual timeframes that addresses the member’s identified needs, removes barriers, and includes goals and interventions to mitigate the risk of re-hospitalization.
- Communicate the member’s care plan to all applicable healthcare providers, ICT and team members involved in the member’s transition.
- Update/revise member care plan goals as indicated.
- A current Michigan Registered Nurse License in good standing (or be willing to obtain immediately).
- 3-5 years of nursing experience, preferably in-home health care, hospital discharge planning, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers.
- Must possess a valid driver’s license.
- Ability to work in a Windows based computing environment to implement evidenced-based care.
- Ability to manage patient complexity and multiple clients with diverse needs.
- Strong interpersonal communication and negotiation skills.
- Strong clinical skills including an understanding of and ability to implement evidenced-based care.
- Strong organizational and time management skills.
- Experience with government programs, including health benefit programs serving vulnerable populations such as Dual Eligible beneficiaries (MMP or DSNP), Medicare Advantage and various Medicaid and State Waiver programs.
- Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care.
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