Transitional Care Coordinator

Salinas Valley Health•Salinas, CA

About The Position

The Transitional Care Coordinator (TCC) ensures smooth transitions of care for patients discharged from the hospital. The role works with population-specific, clinic-specific, insurance-specific, high-risk, and virtual home program patients to reduce hospital readmissions, improve patient outcomes, and enhance patient satisfaction. In collaboration with physicians, hospital care teams, and patients’ families or significant others, the TCC assesses and implements individualized plans of care. The coordinator works with Transitional Care Program Leadership, the Transitional Care Social Worker, Case Management staff, and other multidisciplinary team members to develop a continuum-of-care plan and ensure patients have the resources and instructions needed to follow it safely. The TCC follows up with patients and their support structures to encourage adherence to medical treatment plans. The position provides education, care coordination, monitoring, triage, and follow-up for at least 30 days after discharge or for the specified program or diagnosis timeframe. Virtual Home Program patients receive an initial call 12–18 hours after discharge, followed by at least daily phone or video calls as needed during the program timeframe. The TCC uses clinical judgment to determine whether patients need immediate in-person care, can be managed remotely, or should be directed to another appropriate provider.

Requirements

Associate degree in nursing.
Current California Registered Nurse license.
Current BLS/Healthcare Provider status in accordance with American Heart Association standards.
Three years of nursing experience.
Working knowledge of community resources, post-acute care coordination, and case management principles.
Bilingual in Spanish.
Broad general knowledge of nursing.
Ability to effectively navigate and use a computerized medical record system.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Case Management experience.

Responsibilities

Meet with eligible patients assigned to the Transitional Care Program before discharge, including Virtual Home Program patients in the Emergency Room when needed.
Introduce the coordinator and the program, and identify immediate barriers or needs related to outpatient care and support.
Call patients within 24–48 hours after discharge to identify barriers to the discharge plan and facilitate resources as needed.
Call Virtual Home Program patients 12–18 hours after discharge and complete phone or video calls at least daily and as needed during the specified program timeframe.
Use clinical judgment to triage patients to immediate in-person urgent or emergency care, remote management, or another appropriate healthcare provider.
Serve as a resource and educator to patients and families for at least 30 days after discharge or for the specified program or diagnosis timeframe.
Intervene on behalf of patients and the organization to reduce avoidable emergency room visits and hospital admissions.
Provide disease-specific patient education, including medication education, in person, by phone, or virtually.
Monitor patient vital signs; reinforce equipment use and vital-sign schedules; record relevant data; alert the healthcare team to critical changes; and track and report laboratory or diagnostic results.
Evaluate each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan addressing medication self-management, use of a dynamic patient-centered record, primary care and specialist follow-up, and awareness of red flags.
Coach patients in addressing critical issues and self-management tasks rather than directly taking over and providing care.
Accurately document patient and family interactions, assessments, interventions, and care plans in the appropriate electronic healthcare record.
Facilitate follow-up appointments with primary care providers and specialists as needed.
Collaborate with Transitional Care Program Leadership and the Transitional Care Social Worker when barriers are identified and action is needed.