Job Description

All About Hamilton Health Center

Hamilton Health Center (Hamilton), established in 1969, is the only Federally Qualified Health Center (FQHC) within a 30-mile radius of Harrisburg, PA and continues to grow using a holistic and comprehensive approach to being patient centered. The mission of Hamilton is to improve the health of Central Pennsylvania\xe2\x80\x99s residents by delivering high quality, respectful and patient-centered health and related social services that promote access, treatment, education, and prevention regardless of health, economic, or insurance status. Our vision is that every member of our community, regardless of their ability to pay or their insurance status, receives holistic, quality health care needed to create a healthy community. For over 50 years we have been true to these words. As part of our team, you will work alongside a dedicated team that cares and values those we serve.

Benefits offered: In addition to your base pay, you are also eligible to receive:

• Paid time off, Catastrophic (CAT)/Sick time, Birthday holiday, and 7 paid holidays.
• Medical, Dental & Vision,
• Company paid life insurance.
• Retirement Plan
• Employee Assistance Program

JOB SUMMARY

The Transition of Care (TOC) Care Manager is responsible for managing a patient\xe2\x80\x99s successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or post-surgical patients of Hamilton. The TOC Care Manager is a member of the Patient Center Medical Home (PCMH) care collaboration team.

This position shall drive assigned activities towards assuring Hamilton meets federal and state regulatory requirements and The Joint Commission quality improvement (QI) and performance measurement standards. This position shall assist and/or drive, as assigned, but not limited to:

• Peer orientation and ongoing training,
• QI project support and coordination,
• Patient safety and quality audits,
• Assessment and analytical evaluation of QI effectiveness,
• Identify opportunities for improvement in patient services and outcomes (gaps in care closure),
• Promote a culture of quality through demonstrated initiative, accountability and professionalism

The TOC Care Coordinator is responsible for managing the post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. This position will work with complex and varied patients and situations. The TOC Care Coordinator will identify hospitalized high-risk, complex patients for program enrollment and communicates with entities involved in the care of the patient to promote and maximize care coordination during and post admission. The TOC Care Coordinator will evaluate under- and over-utilization to ensure appropriate emergency room utilization and hospital readmissions.

ESSENTIAL FUNCTIONS:

TRANSITIONAL CARE MANAGEMENT \xe2\x80\x93 IDENTIFICATION, ASSESSMENT AND INTERVENTION * Identifies patient/family education needs through assessment to ensure that patient/family members have adequate information to participate in discharge and transition planning.

• Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate/maintain the patient\'s transition plan of care.
• Critically evaluates and analyzes physical and psychosocial assessment data.
• Performs medication reconciliation and partners with provider to address discrepancies, contraindications and/or side effects which present as barriers to medication adherence.
• Assesses complexity of care needs and potential/actual issues or gaps in care.
• Conducts health literacy assessment using a defined industry proven tool (e.g., REALM).
• Interprets screening and selective laboratory/diagnostic tests.
• Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
• Acquires and assimilates new and existing information into care plan delivery to meet the needs of the patient.
• Utilizes financial and insurance resources as well as Hamilton\xe2\x80\x99s assistance programs (i.e. Medical Assistance Program) to maximize the health care benefit to the patient.
• Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.
• Advocates for patients and families within the health care system with community providers and across the continuum of care.
• Identifies, tracks, and conducts root cause analyses on 30-day readmissions to address programmatic and systemwide improvements.
• Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources regarding unanticipated variances.
• Directly supports the implementation of QI/QA operating procedures, completion of QI/QA assessments, monitoring QI/QA outcomes, and updating QI/QA operating procedures as warranted, specifically in the area of transition of care programming.
• Assist Quality Director and Compliance Officer with ensuring execution on established infection prevention, exposure control and, when indicated, pandemic plans.
• Interacts and cooperates with Hamilton administration and departments to promote integrated patient care services (e.g., PCMH) to further the mission of Hamilton.

RESEARCH, EDUCATION AND BEST PRACTICE IMPLEMENTATION

The TOC Care Manager utilizes research findings in practice and participates in TOC program design, implementation, and evaluation and participates in ongoing quality improvement activities. The TOC Care Manager collects clinical path variance data that indicates potential areas for system-wide improvement of care and service. The TOC Care Manager seeks to resolve errors and discrepancies through a broader system approach. * Participates in organizational and partner research surrounding transitional care.

• Identifies recurring clinical practice issues and contributes to the development of specific plans to address identified issues.
• Participates in activities that support the advancement of care transitions, case management, and discharge planning through literature review, professional organizations, research, committee participations, training and education for peers/organization, etc.
• Demonstrates expertise in transitional care management and consistently uses new knowledge, technology, and research in practice.
• Develops, implements, and evaluates comprehensive proven clinical practice guidelines, expert guidance, and nationally-recognized research to support program evaluation that assure quality and appropriateness of care across settings.

PROFESSIONAL DEVELOPMENT AND ENGAGEMENT * Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.

• Work collaboratively with Quality Director in the development and implementation of a quality management strategy and annual goals.
• Serve as a preceptor and educate new staff on performance improvement activities and approaches to promote successful delivery and/or process revision for quality outcomes.
• Provide educational offerings in area of expertise at Hamilton and its affiliates, the Quality Department, PCMH Care Coordination Team, and in the community.
• Serve as back up to the Quality Director to present agenda items and lead discussion on the Health Services Committee.

Minimum Education/Certifications: Active, RN or LPN license with 2 years of applicable clinical background required; Bachelor\xe2\x80\x99s degree in Nursing, Health/Human Services or related field preferred.

Minimum Work Experience: Experience with accreditation surveys (e.g. The Joint Commission), and regulations. Experience with transition of care and/or care coordination activities preferred. Highly proficient in Microsoft Office products suite (e.g., Word, Excel, PowerPoint, Outlook; VISIO is a plus) and proficiency in working within Electronic Health Records. Knowledge of PDSA improvement approaches and experience implementing. Bi-lingual in Spanish preferred.

Knowledgeable in The Joint Commission regulations, preferred. Bi-lingual, preferred.

This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position\'s responsibilities.

PI224593342

Hamilton Health Center