Continuum Coordinator (C2) Discharge Planner

Trinity Health

9d•$24 - $31

About The Position

The Continuum Coordinator (C2) Discharge Planner collaborates with the Clinical Care Manager, physicians, and the health care team to manage the progression of patient care using evidence-based best-practice guidelines. The role engages patients and care teams in managing key patient outcomes and transitions to the most appropriate post-acute setting. As a patient advocate focused on the whole patient experience, the coordinator supports communication and patient flow across the continuum and serves as a resource to staff, patients, and families. The position contributes to a patient-focused environment where the hospital mission is actualized, outcomes are achieved, and high-quality practice is realized. The position works day shift, 7:00 a.m. to 3:30 p.m., Monday through Friday, with a weekend rotation every 12th week. The stated pay range is $23.80–$31.40; pay is based on experience, skills, and education, and may vary by location.

Requirements

Associate degree in a health-related field.
Three years of experience in a health-related field.

Nice To Haves

Working knowledge of discharge planning and community resources.

Responsibilities

Engage patients and families in discharge planning and provide educational resources about service choices, costs, and scope under the direction of senior staff.
Facilitate referrals to home care agencies, rehabilitation providers, durable medical equipment vendors, home infusion vendors, home labs, and other programs as directed by the Clinical Care Manager.
Assist with prior approval or preauthorization from insurance for post-acute care services.
Identify and address barriers by providing information and referrals to entitlement and insurance programs, hospital resources, and community organizations.
Explain the Medicare Important Notice, appeal rights, and qualifying hospital-stay requirements for subacute rehabilitation coverage when appropriate.
Facilitate patient transfers in accordance with hospital policies, applicable state and federal regulations, and Joint Commission standards.
Document information pertinent to the transitional plan of care and clearly document the discharge plan for post-hospital care providers.
Provide patients and families with information about discharge planning, length of stay, appropriate use of health care resources, and the appeal process.
Make timely referrals to community services based on identified needs to ensure continuity of care.
Advocate for culturally competent care and information appropriate to patients’ literacy levels.
Escalate patient quality concerns to the Clinical Care Manager or unit leadership, attend Patient Safety and Quality reviews as needed, and report variances through established quality-improvement processes.
Verify patient identification before discharge handoff to external providers.
Identify and appropriately document avoidable days that contributed to increased length of stay.
Use the teach-back process to ensure patients and families understand the discharge plan.
Identify variances in care and escalate them to the Clinical Care Manager or local leadership.
Support timely progression to appropriate levels of care and advocate for care in the right setting and at the right level.
Ensure discharge arrangements are timely to facilitate patient flow.
Serve as a role model in support of the hospital mission and participate in unit-based interdisciplinary meetings in a patient-centric manner.
Develop and mentor C2 Discharge Planning staff as necessary, foster teamwork, and recognize team members’ strengths and expertise to develop and implement patient-centric plans.