Care Transitions Coach - RN

Care Transitions Coach - RN -- Resource Center for Case Mgmt -- General Hospital (Job )

Job Summary

The Care Transition Coach coordinates care across an episode of illness of the patient with multiple chronic conditions. Utilizes the nursing process to develop individualized plans of care for safe and effective movement of patient across the care continuum, serving as the bridge between the professional staff in a care setting and the patient and/or family. In this role, as a patient educator-advocate, and patient empowerment facilitator, the Transition Coach utilizes education and community services to develop patient/family/caregiver problem solving and self management skills.

Fosters communication, builds collaborative relationships and enables patient/family/caregiver to better navigate the health care system. Focuses knowledge deficits and behaviors that interfere with recovery, cause harm or re-hospitalization.

Responsibilities

• Essential Duties:
  Utilizing the nursing process in the coordination of care across an episode of illness + from inpatient to rehabilitation and/or home settings in accordance with policies and procedures and within the framework of patient and family centered care.
• In Hospital Components:
  Performs initial and ongoing assessments to determine general health behaviors, practices and resources that will influence the patient and family's ability to optimally manage the chronic condition(s). Assesses substance abuse including tobacco, alcohol, and prescription medications; collaborates with physician to develop plan for substance reduction (i.e. smoking/tobacco cessation, etc.) Collaborates with health care team to determine extent of functional deficits and areas for potential improvement.
  
  Assesses emotional status and quality of relationships and adequacy of social support systems, identifying new sources of support. Assesses self-management consistent with level of caregiver support and patient competency. Identifies and manages post discharge safety risks. Addresses knowledge deficits and behaviors likely to interfere with recovery, cause harm or re-hospitalization. Partners with patient/family/caregiver and collaborates with health care team to identify patient specific needs, risk and capabilities.
  
  Assesses home environment and reduce/eliminate factors that could increase fall risk. Prioritizes immediate plan for transitional care to include medication availability and family support. Nurtures an environment of dignity and respect for the patient/family and caregiver. Respects the patient's cultural, religious and spiritual considerations.
• Post Discharge Needs:
  Assures patient/family/caregivers understand and has access to all prescribed post discharge therapies. Promotes patient adaptation by focusing on:
  Managing problem behaviors and risk factors to prevent further decline. Assessing and managing physical and emotional symptoms within scope of practice. Promoting adherence to medications prescribed, therapies and medical management. Partner with patient/family/caregivers in identifying precise symptoms that indicate a worsening of his/her condition or a sign that there is a problem with prescribed therapy. Assure understanding by patient/family/caregivers of symptoms, a general management plan and an emergency plan for each unique symptom.
  
  Teaches patient/family/caregivers strategies to maximize self participation in care within functional limitations. Enlists support from family/friends/caregivers/referral agencies to compensate for patient deficiencies. Promote patient specific healthy behaviors.
• Evaluation and Plan of Care:
  Reassesses patient and/or family response to care and the patient/caregiver ability to navigate the health care system. Reports pertinent findings to physician and other members of the healthcare team. Partners with patient/family and collaborates with physician to modify the plan of care as needed, addressing the individual needs of the patient and family. Fosters communication and builds collaborative relationships.
• Safety and Quality:
  Actively participates in Patient Safety and Quality Improvement initiatives. Displays individual responsibility and investment in patient care outcomes and key organizational goals. Through coordination of care and promotion of self-management, decreases re-hospitalization. Responsible to coordinate development of the quality improvement plan for areas of responsibility. Work with Corporate and Clinical Directors to implement…