JOB DESCRIPTION
TITLE: Transition Care Coach
JOB CODE:
335
GRADE:
E3
DEPARTMENT:
Transition Coaching
BENEFITS:
EFFECTIVE DATE: 5-21-10
REVISES: 07-20-11
REVISED: 6/06/13
FLSA STATUS:
EEO STATUS:
PAGE:
FUNCTION:
Acts as facilitator of interdisciplinary collaboration and care continuity
across care settings, coaching patients and caregivers to play an active
and informed role in care plan execution utilizing the Coleman Model
and/or adaptations required by insurer.
REPORTS TO:
Director Specialty Programs
HOURS:
Monday to Friday 8:30-5pm with occasional need to flex days and hours
based on patient need.
RELATIONSHIPS:
Patients, families, hospitals and care and discharge planning team
members, physicians, community agencies, insurers and other health care
providers in the community.
RESPONSIBILITIES:
1. Participates and assures that the Care Transitions Services are consistent with the pilot design and
meets customer needs.
A. Promotes the Care Transitions philosophy and ensures the delivery of quality care.
B. Promotes effective working relationships and works effectively as part of the pilot project to
meet the goals and objectives established.
C. Promotes positive, supportive, respectful communications to all external sources, patients,
families and staff.
2. Develops and maintains a customer oriented environment responsive to the needs of all
external/internal customers.
Direct Coaching Duties:
A. Initial case finding and screening of patients by group. Hospital/ED contact with patient
for final screening and completes Hospital Visit intervention for the Care Transitions
Program.
B. If patient appropriate for program, contact insurer as required regarding program
enrollment and obtain any needed authorizations. Interfaces with VNS intake
department for referral generation.
C. Begin interactions regarding patient goal setting and the role of the transition coach.
D. Be sure patient has initial Primary Care Physician (PCP) appointment set before
discharge.
E. Arrange for first home visit within 24-72 hours.
F. Initiate the use of the Personal Health Record (PHR), complete assessments as needed
i.e. Patient Activation Measure (PAM) and/or Patient Activation Assessment. Completes
documentation in electronic record day of service.
G. Maintains journal of interventions and coaching “stories” for use in program evaluation
and program development.
H. Establish visit schedule and continue to act as patient educator – advocate, and patient
empowerment facilitator to move patient to improved self management skills and
enhanced patient – practitioner communication.
I. Assure coordination and communication between patient and all care providers.
J. Complete follow up telephone calls with patient to check status and document.
K. Maintain open communication with insurer Disease Care Managers.
L. Maintain and provide data as requested to demonstrate project progress.
M. Manage caseload of approximately 30 patients and assure productivity per standards.
N. Communicates effectively and works collaboratively with hospital care and discharge
planning staff to assure successful care transition coaching. Assures all requirements met
for contract staff status at respective hospitals met.
O. Participates in grant projects and studies involving transition coaching as required.
QUALIFICATIONS:
1.
RN, MSW, or Other allied health professional
2.
Minimum of 1-2 years experience in the home care, health care or community based
organization. .
3.
Strong communications and organization skills
4.
Spanish speaking is a highly desirable
5.
Knowledge of medical terminology
6.
Ability to be flexible and adjust practice based on patient population being served.
7.
Strong education/teaching background
8.
Experience in managing complex problems and developing creative solutions.
APPROVALS
DEPARTMENT:
ADMINISTRATION:
HUMAN RESOURCES: