Home Health Care Transition Coordinator

Company:

Position Summary

Registered Nurse highly preferred. LPN considered. Monday - Friday, 8AM - 5PM. Role will be based at Ascension Columbia St. Mary's Hospital - Milwaukee Campus.

The Home Health Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Care Transition Coordinator serves as a trusted resource for the physician and hospital case managers and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Health Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Meets regularly with physicians in the hospital to discuss specific patients: gives guidance and provides an understanding of post-acute service support; ensures continuity of care as a priority.
• Acts as hospital case managers (rounding or interactions in step with the hospital): high-risk patient reviews.
• Supports transition to home health, home infusion, and hospice services by conducting in-person bedside transitions; where services are offered.
• Educates on hospice, home infusion, and home health benefits to patient families and referral sources.
• Develops genuine collegial relationships with other Ascension professionals and identifies times to meet regularly with clinicians to problem solve and review cases.
• Understands how to interact with difficult patients/families.
• Identifies steps to having a successful family meeting.
• Develops communication skills to support patients/families with difficult discussions or differing points of view.
• Maintains a current list of admission coordinators for each healthcare service line.
• Aligns recommendations between patient/family and Primary care team:
  • Identifies patient preferences/needs.
  • Identifies patient’s post-acute care needs.
  • Confirms the level of care most appropriate for the patient - right care, right time.
  • Educates patient on Homebound criteria and verifies patient meets this requirement.
  • Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing a transition to the home plan.
• Sets patient-centered goals and facilitates transitions:
  • Understands how to identify patient/family-specific treatment goals.
• Arranges for home admission – communication with the Home Health and Home Infusion team(s).
• Coordinates patient care by obtaining H&P, physician orders, hospital records, and face-to-face documentation promptly.
• Verifies patient demographic information is correct.
• Coordinates organization of transfer orders; educates patients on home care orders and home care services.
• Identifies primary care physician to follow the plan of care.
• Conducts follow-up on re-hospitalized home health patients.
• Participates in home health re-hospitalization mitigation strategies – be a member of the strategy team.
• Develops ability to understand and digest claims data, and use of predictive analytics.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts.
• Consistently works to improve personal knowledge and sales skills to become of greater value to our most important customers and the company.
• Meets or exceeds assigned quotas, thereby maintaining and constantly improving the HH's competitive position.
• Performs other duties as assigned.

Education and/or Experience

• Bachelor’s degree preferred.
• Two (2) to three (3) years of nursing experience as an RN highly preferred. LPN would be considered.
• Hospital and/or long-term care clinical experience highly preferred.
• Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, introduction to end-of-life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, and estimating and communicating prognosis/disease trajectory preferred.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.

Certifications, Licenses, and Registrations

• Active and unencumbered Registered Nurse license in the state(s) of employment. A Graduate of an accredited Licensed Practical/Vocational Nurse program considered.

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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