Transitional Care Coordinator; Liason, Sales - Homecare

Overview

Transitional Care Coordinator (Liason, Sales) - Homecare

Location Detail: 81 Meriden Ave Bradley Memoria (10003). Work Location Type:
In Person. Work where every moment matters.

Hartford Health Care at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our colleagues to learn and grow within our organization, all while providing integrated support to the patient. Most importantly, our colleagues are appreciated for the real differences they make in both the lives of their clients and their clients’ families.

Basic Purpose Of The Position:
Work in collaboration with hospital case managers and/or social workers, skilled nursing facilities, Assisted living facilities, Independent Living Facilities, home care agencies, and physicians to provide education to customers, patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patient’s transition across the post-acute care continuum. Serves as a bridge between the healthcare team and the patient and/or caregivers, as well as helps to reduce facility re-admissions.

Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge of their illness and/or disease process in addition to supporting enhanced communication between the patient and the healthcare team. Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referrals and building new clinical initiatives.

• Strives to reach / exceed corporate assigned admission goals for all service lines
• Building relationships and trust across the continuum
• Marketing HHCAH service lines for system and non-system partners
• Identifying patients at risk during transition to home (or SNF) using standard tools of assessment
• Review demographic and clinical information and ensuring accuracy of information in the transition from one setting to another

• Chart review completed upon notification of the referral is as follows:
• Review key information from Home Care Home Based / hospital chart (e.g. patient demographics, history and physical exams, comorbidities, other hospital services received such as therapy and ongoing needs)
• Identify DME/supplies and company with contact information and document for HHC@H team
• Identify critical/high risk medications/labs/care that need next day start of care and document for HHC@H team
• Identify if patient has CCCI, Agency on Aging, WCAA, CHCPE, ICP, Pro Health and/or ACO services and document for HHC@H team
• Communicate information that is essential in formulating an effective plan of care to HHC@H staff in conjunction with supportive documentation
• Monitor all current/new patients while at hospital / SNF & ALF and alert HHC@H team when start of care will be needed
• Document current/new HHC@H patients that transition from acute setting to SNF with co-TCC following up with SNF to capture that patient once short-term rehab is completed
• Assist transitioning complex case / high risk patients home in collaboration with Care Coordination / hospital team / patient / family
• Conducting an “at the bedside” meeting with the patient and/or caregiver and following the patient during the post-discharge transitional phase. During Bedside visit:
  Patient visual assessment, education on disease process, clinical review, social review may be done. Following up with the patient to ensure that the patient is following transitional plans and goals of care.

• Bedside Visit May Include But Is Not Limited To
• Determine the patients language interpretation needs
• Identify skilled need and homebound status
• Identify location the patient will be receiving home care services
• Assessing patients health literacy and using teach back method as learning tool
• Identify primary caregiver with contact information, including alternate contact information
• Identify high risk patients and/or barriers to discharge
• Confirm patient has transportation to appointments
• Engage in…