Job Description

Description Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details:

Work where every moment matters.

Every day, almost 30,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut\xe2\x80\x99s most comprehensive healthcare network as a Transitional Care Coordinator.

Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient. As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client\xe2\x80\x99s home. Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients\xe2\x80\x99 families.

Basic Purpose of the Position:

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\xe2\x80\x99s 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 \xe2\x80\x9cat the bedside\xe2\x80\x9d 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)

Identify home care services and additional services warranted, if applicable (i.e. HOPE / Hospice, -Independence at Home, Center for Healthy Aging, Healthy Minds (Dementia, Behavioral Health), TCRN, SNF)

Patient/family education that we provide is as follows:

-Introduce concept of home health services, provide brief overview of agency

-Explain HHC@H will be in contact within 24- 48 hours to schedule the first home care visit

-Discuss the patient\xe2\x80\x99s personal goals, explain HHC@H team will assist and discuss detailed plan of care during SOC visit

-Educate patient and family members in disease management utilizing hospital educational materials, teaching of RED FLAG signs/symptoms and utilize teach back technique to validate patient/caregivers understanding

-Notify patient/family of copay or other financial obligations as appropriate

-Ensure patient has HHC@H TCC\xe2\x80\x99s contact information for questions

-Attend family meetings as appropriate

-Identify solutions and advocate for resources including discussion on specialty services

-When applicable, reviewing the hospital discharge summary and medication list with patient/caregivers and assuring the transitional care processes are implemented by engaging patients and care givers in health self-management, including medication management.

-Initiating Personal Health Record and emphasizing patients\xe2\x80\x99 early recognition of health care risks and symptoms to achieve longer term positive outcomes and avoid adverse events, such as re-hospitalization

-Performing pre-discharge patient and family assessment to determine understanding and acceptance of discharge plan and orders in conjunction with discharge planning staff to ensure a smooth transition home.

Follow Up Case Coordination/Social Services of health care services:

-Daily collaboration with Care Coordination/Social Services acute-system, non-system, acute rehab, SNF and ALF. (SNF TCCs rotating schedule of their centers) on active/potential referrals as needed

-Confirm if patient has been or is active with HHC@H upon request

-Notify Care Coordination/Social Services when past/active patient hospitalized

-Collaborate with Care Coordination/Social Services on discharge date, after care needs, equipment and pertinent information obtained during bedside visit

-Make recommendations to case management, social worker, hospitalists for post-acute services for any patient

-Document patient information attained during bedside visit and case management collaboration for the clinical team

-Present HHC@H Patient Care Form to patients that have proven compliance issues with specific details discussed prior to patient\xe2\x80\x99s discharge

-TCC\xe2\x80\x99s are available to Care Coordination for collaboration on all patients referred to or inquiring HHCAH

-Collaborating and communicating with Primary Care Providers and home care staff to insure continuity of medical care through follow up appointments

-Preparing and maintaining accurate patient records, charts and documents to support sound medical practice

-Notifies appropriate hospital or physician personnel when patient is having difficulty following the transitional care program, helps to identify and remove barrier to goal attainment, and assists with intervention as needed

-Consistently communicates with HHCAH management to make sure all issues and problems are seamlessly handled so that both the patient and the SNF/hospital/physician are satisfied with the results and process.

-Participating in case conferences and or rounds at the request of hospital and/or community agency staff

-Providing consultation to hospital staff and or skilled nursing facilities on community resources and home care issues

-Adheres to the practice of confidentiality (HIPAA and other state/federal regulations) regarding patients, families, staff and the Agency

-Schedule education to our customers using appropriate HHCAH personnel

Qualifications

Licensure: RN or LPN with an active license to practice in the State of Connecticut.

Education: Bachelor\xe2\x80\x99s Degree preferred; Associates Degree Nursing license required

Experience: Minimum of 1 year recent homecare experience preferred

Skills/Desired attributes: Positive outlook, Effective communicator, Computer literacy including Microsoft Office and Excel, efficient multi tasker, experience and interest in problem resolution and process improvement. A creative thinker that excels in team environment.

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge \xe2\x80\x93 helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.

Hartford HealthCare