Part-Time Transition Coach, LMSW or RN

AdventHealth•Shawnee, KS

35d•Onsite

About The Position

The Transition Coach will implement the Shawnee Mission Health Readmission Prevention model targeted to reduce the number of patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. The Transition Coach will initially meet patients in the hospital and will follow selected patients who transition from the hospital to a lower level of care. Patients will be identified by various methods including the use of Cerner Quality Consoles, Care Coordination meetings and the BOOST tool. Strategies for patient management include but are not limited to Teach Back method of discharge instruction, assistance in setting up PCP appointment within 72 hours, home visits to assist with medication reconciliation and other self -management techniques, ongoing telephone follow up, assistance with psychosocial issues and gaps in service and support of caregivers as appropriate. Transition management will be provided to patients who discharge to a destination other than home and the strategies will be appropriate to that level of care. The Transition Coach will work as part of an interdisciplinary Transitions Team including acute care case managers, social workers, home care liaisons, physicians, pharmacists, nursing leadership and staff nursing. This position will also work as part of various other teams, including the Continuing Care Team on each unit. The Transition Coach will also participate in routine readmission meetings with community partners as well as comply with data collection expectation

Requirements

1 Work Experience Required
Registered Nurse (RN) Kansas Required or
LMSW

Responsibilities

Identifies patients with moderate to high-risk conditions for readmission and collaborates with the treatment team to ensure safe and effective transitions of care.
Assesses, educates, and provides interventions for patients and families in disease self-management both during the hospital stay and post discharge.
Assesses medication adherence and regimen and provides education with interventions to improve the patients medication compliance.
Coordinates care of patients at risk for readmission from discharge through 30-90 days post discharge.
Arranges post-acute resources for patients requiring additional support post-discharge from the hospital.