Care Transition Coordinator

Dimensions Health Care Hyattsville, MD
Overview

Under the direction of the Manager of Ambulatory Care Coordination, the Care Transition Coordinator provides comprehensive care coordination to high risk patients post discharge. The Care Transition Coordinator is directly involved in managing the multiple elements that comprise a person's successful transition from hospital to home. He/she refers patients to the appropriate transitional care program(s), manage the post discharge automated call system and develop professional internal/external relationships to ensure that safety and high quality care is provided in an outpatient setting.

ResponsibilitiesTakes the lead in ensuring the continuity and consistency of care extending beyond the acute care setting. Serves as a liaison to acute care hospitals and post-acute care services to facilitate comprehensive discharge planning and follow up care.Assesses and identifies patient risk factors and self-management skills. Reinforces discharge instructions, medication reconciliation, assesses for the presence or absence of a support system, identify barriers to care, and emphasizes the importance of timely outpatient follow up to prevent readmissions.Manages the Connect automated call back system by following up on daily alerts and resolving patient issues/concerns.Receives high risk patient referrals via handoff from the ED, inpatient, and ambulatory care settings; promotes clear communication amongst the care team and treating clinicians.Meets with patient/family in the hospital setting to introduce role, build rapport and reinforce the discharge plan.Coordinates referrals to needed providers and community services as appropriate.Educates the patient/family about key self-management strategies using tools appropriate for the patient's health literacy, cultural background and level of engagement.Develops effective working relationships with Physicians, Nursing, other ancillary departments and referral sources.Documents all interventions per Ambulatory Care Program standards.Attends multidisciplinary rounds as required.Participates in trainings, various workgroups and committees within, and outside, the organization.Participates in data collection as directed.Qualifications

Licensure as a Practical Nurse in the State of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing