Ambulatory Transitions of Care Navigator

Description

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives—and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better—advancing our mission to transform healthcare and serve as a leader of positive change.

The Ambulatory Transitions of Care Navigator is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of patients discharged from HMH Hospitals and attributed to our Primary Care Providers. The navigator is accountable for a designated case load determined by the daily selection of eligible patients (Non‑ACO/CIN Patient Population). They assess, plan, and facilitate, with patients/families and healthcare professionals involved in the patient’s care, to meet treatment goals and arrange for the appropriate next steps.

They oversee coordination and handoff between acute and outpatient services.

A day in the life of an Ambulatory Transitions of Care Navigator at Hackensack Meridian Health includes:

• Program eligibility and guidelines are established by the Network under the direction of the Ambulatory Quality and HMHMG operational executives. All patients who are discharged from an HMH hospital who are attributed to HMHMG Primary Care Providers (Non‑ACO/CIN populations) are currently considered for program enrollment. This may evolve as organizational needs change. All eligible patients will be enrolled.
• Outreach to the patient/family/caregiver to assess needs and develop an individualized needs assessment for planning.
• Facilitates communication and coordination between members of the health care team and involves the patient/family/caregiver in the decision‑making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care.
• Develops a Transitions of Care (TOC) plan, in collaboration with the patient/family/caregiver, support services and healthcare team to facilitate the maximum benefit for each patient. Coordinates hand‑off between transitional care team members as needed; primary care provider, specialist, community resources, referrals, and/or service providers, to meet patient transitional care needs.
• Brings forth issues which impact patient transitions as well as the risk of readmission for discussion and resolution with the patient’s care team.
• Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the appropriate level of care.
• Maintains current and up‑to‑date information of community resources and refers patients to those community resources which will enhance patient’s life and clinical outcomes. Consults with other community agencies and committees to identify potential resources to support patients and their families. Will actively work with the Social Determinants of Health (SDOH) team to find community partners.
• Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient’s medical history, coordination of follow‑up care, and referrals.
• Provides patients and families with resources and discharge care coordination options.
• Participates actively on appropriate work groups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Manager.
• Reassesses periodically and evaluates against care goals and the plan of care, and, when indicated, revises the plan or goals.
• Medical records reflect that each patient’s TOC plan is re‑assessed in response to changes in patient’s needs and Social Determinants of Health. Supports long‑term patient wellness and helps prevent readmission by enrolling eligible patients in ongoing health management programs after their transition…