Care Transitions Coordinator - Registered Nurse
Under the supervision of the NHA the Care Transition Coordinator assumes responsibility and accountability for collaborating, directing, following and coordinating the care and services provided by skilled nursing facility staff to align with assigned patients’ goals as well as those of acute and post-acute continuum of care providers. Leadership is provided to Interdisciplinary team through team meetings designed to communicate each patient plan of care and goals. Care Transition Coordinators adhere to the standards of care, manage the environment to maintain resident/patient safety and ensure Customer satisfaction throughout stay. Follows all Extendicare policies and procedures and performs duties as defined by the State Nurse Practice Act.
This position requires an active RN license in Michigan, experience with post-acute care settings, physical assessments and team collaboration.
Primary responsibilities include but are not limited to the following:
- Coordinates the work of employees to meet patient goals and expectations
- Pre-admission onsite visit with medical record review, patient/responsible party and hospital caregiver interviews to facilitate coordinated care upon admission to skilled facility ( where feasible)
- Assists with resolution to all short stay patient/family concerns. Communicates opportunities for improvement to Department Managers
- Participates in training programs and assists in orientation of all staff
- Attends stand-up meeting and reviews 24 hour report
- Daily review of planned admissions and re-admissions as well as re-admissions to hospital within 30 days of admission to skilled facility
- Attends daily triage and clinical meetings as well as interdisciplinary care meetings for all short stay patients
- Reviews daily documentation on assigned patients to include Physician Orders and ensures follow through consistent with patients’ plan of care
- Coordinates patient and responsible party education regarding disease process and management with interdisciplinary team to include medication management at time of discharge and as part of post discharge follow up.
- Communicates Recovery Track plan to assigned patient and responsible party throughout stay
- Facilitates reintegration into community with Social Services staff, patient, responsible party and post skilled facility partners to include Primary Care Physician follow up appointment, notification of discharge and summary of stay.
- Manages Extend to Home program for all discharges. Tracks and trends results and assists in resolution for individual concerns as well as identified, trended opportunities for process improvement
- Coordinates assigned patient population care with acute and other post-acute providers including arrangement for Primary Care Physician follow up visit.
- Participate on project teams with acute and post-acute providers to develop processes, tools and programs to reduce avoidable re-admissions and improve patient outcomes
- Utilizes care cost estimator for all short term admissions in order to track and assess costs and opportunities for efficiencies moving forward.
Qualified candidates should apply on line at www.extendicare.com or send resume to Kurt Conrath at email@example.com
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