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Transitional Care Coord / Sales and Business Development

Requisition ID:

20154463

Business Unit:

Hartford HealthCare at Home

Location:

Southington, CT

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Description

Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details: Transitional Care Coordinator will be stationed at The Hospital of Central Connecticut-New Britain Campus.

Excellence, Safety, Caring, Integrity….What do you value?

 

Join us at Hartford HealthCare at Home as we live our values every day. As part of Hartford HealthCare we create a better future for healthcare in Connecticut and beyond. By embodying these values we have become nationally respected for patient care and most trusted for personalized coordinated care. Come be part of something special!

For over 115 years, Hartford HealthCare at Home has been fulfilling our mission by enabling individuals to achieve maximum independence, participate in their own plan of care, and to live with dignity while receiving quality care in their own homes. Our dedicated caregivers of HHC at Home use the latest in research and education to develop a coordinated, consistently high standard of care for all its customers

The Transitional Care Coordinator works in collaboration with hospital case managers, skilled nursing facilities, home care agencies, and physicians to coordinate the care of patients moving from one level of care to another to insure a safe transition across the post-acute care continuum.  Serves as a bridge between the healthcare team and the patient and/or caregivers.  Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge, and enhanced communication between patient and healthcare team.  Responsible for building and expanding our relationships as well as identifying opportunities to be a strategic partner, generating qualified referrals and building new clinical initiatives.

Duties Include:

Building relationships and trust across the continuum of practices and facilities;

Identifying patients at risk during transition to home care (or SNF) using standard tools of assessment

Reviewing demographic information and confirming accuracy using patient record and patient and/or patient caregiver

Conducting "at the bedside" meeting with patient and/or caregiver and following patient during the post-discharge transitional phase.  Following up with the patient to ensure that patient is following transitional plans.

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.

Reviewing 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.

Assessing patients' health literacy and using teach back method as learning tool.

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

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 barriers to goal attainment, and assists with intervention as needed

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

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

Provides consultation to hospital staff on community resources and home care issues

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

Qualifications

CT licensed LPN, RN, BSN preferred. BA, BS or previous marketing experience

Three years experience in marketing, clinical liaison  or network account management. Home care experience preferred


 
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