Transitional Care Coordinator Valley Health

The Transitional Care Coordinator (TCC) is responsible for ensuring smooth transitions of care for patients being discharged from the hospital setting. The TCC will work with population specific, clinic specific, insurance specific, high-risk, or virtual home program patients to optimize recommendations focusing on reducing hospital readmissions, improving patient outcomes, and enhancing patient satisfaction. In collaboration with the physician, hospital care teams and family/significant others, the TCC will assess, evaluate, and implement a plan of care for the patient.

The TCC works collaboratively with the Transitional Care Program Leadership team, Transitional Care Social Worker, Case Management staff and other members of the multidisciplinary team to develop a Continuum of Care plan to assure patients have the resources and instructions to carry out the plan safely. The TCC will follow up with the patient and the patient support structure to ensure compliance with the medical treatment plans.
* 1. Prior to discharge, meets with eligible patients assigned to the Transitional Care Program, including Virtual Home Program patients in the Emergency Room when needed.
* 2. Introduces self, program, and identify immediate barriers/needs to outpatient care/support.
* 3. Calls patients within 24-48 hours post discharge to identify any barriers to success in the discharge plan. Facilitates resources as needed.
* 4. Virtual Home Program patients are called 12-18 hours after discharge. Phone or video calls to these patients are completed at least daily and as needed throughout specified program time frame. The TCC will need to utilize clinical judgment to triage patients, deciding if the patient requires immediate in-person care in the urgent care or emergency room, if they can be managed remotely, or can be directed to other appropriate healthcare providers.
* 5. Serves as a resource and educator to the patient and her/his family for a minimum of 30 days post discharge or specified time frame depending on the program/diagnosis.
* 6. Intervenes on the behalf of the patient and organization to reduce avoidable emergency room visits or hospital admissions.
* 7. Provides disease specific patient education including medication education as needed. Education may be in person while in the hospital, telephonic, or virtual.
* 8. Monitor patient vital signs, reinforcing proper use of equipment and reinforcing education on vital sign schedule. Recording relevant data and alerting healthcare team to any critical changes. Tracking and reporting lab or diagnostic results.
* 9. Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication-self management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags.
* 10. Serves as a guide to the patient, coaching the patient in addressing critical issues and self-management tasks rather than directly taking over and providing care.
* 11. Accurately documents all patient and family interactions, assessments, interventions and care plans in appropriate electronic healthcare record.