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Transition of Care Coordinator

2 months ago

Windsor, United States Southern New England Healthcare Full time $56,075 - $72,897
Job DescriptionJob Description

SUMMARY OF ROLE:

The Transition of Care Coordinator (TOC) is a Licensed Practical Nurse responsible for coordinating the care of patients during transitions from one healthcare setting to another, such as from a hospital to a home environment. The TOC Coordinator ensures that these transitions are safe, smooth, and effective, helping to reduce rehospitalizations. This role focuses on coordinating care and improving patient outcomes during these critical transitions. The coordinator works closely with patients, families, and healthcare providers to ensure that transitions are safe, effective, and patient-centered.

This role is located at the company's headquarters in Windsor, CT, and operates in a semi-virtual environment.

Primary Responsibilities:

  • Care Coordination:
    • Facilitate and coordinate the transition of patients from one care setting to another effectively communicating post-discharge information and care plans.
    • Identify gaps in care and implement individualized transition plans that address these gaps focusing on the medical, social, and emotional needs of patients.
    • Educate patients and families about their care plans, medications, follow-up appointments, and available resources.
  • Patient and Family Support:
    • Educate patients and their families about understanding their discharge instructions and care plans, the transition process, including medication management, follow-up care, and potential symptoms to monitor as well as self-management.
    • Provide emotional support and address any concerns or questions that patients and families may have about their care.
    • Connect patients with community resources, such as home health services, transportation, and support groups.
    • Coordinate with community health workers, case managers, and other healthcare professionals to connect patients with community resources and support services.
  • Communication and Collaboration:
    • Act as the primary point of contact for patients, families, and healthcare providers during care transitions.
    • Collaborate with interdisciplinary care teams to ensure that care is coordinated and that patients receive the necessary services and support, including hospital facilities, payors and home care agencies.
    • Maintain clear and accurate documentation of all care transition activities, communications, and patient interactions.
    • Willing to learn and adapt to workflow changes reflective of the health care system continuously evolving nature.
  • Follow-Up and Monitoring:
    • Conduct post-discharge follow-up calls to assess patient progress, address gaps in care, and reinforce plan of care.
    • Work to reduce rehospitalizations by identifying and addressing potential barriers to successful care transitions.
  1. Monitor patients for any signs of complications or readmission risks and coordinate timely interventions, if needed, to the least restrictive environment.
  • Quality Improvement:
    • Participate in quality improvement initiatives related to care transitions, including data collection and analysis, process improvement, and staff education.
    • Identify opportunities to enhance the care transition process and contribute to the development of best practices.
    • Provide an integrated approach to build health equity.
    • Stay informed about current trends, research, and regulations related to care transitions, including CMS guidelines.
    • Support population health department goal of reducing rehospitalization within 30 days.

Qualifications:

  • Graduate of accredited Licensed Practical Nurse program.
  • Active and valid LPN license by state of CT. Additional MA state license preferred.
  • Minimum three (3) years nursing experience.
  • Minimum of 2 years in care coordination, case management, or a related field, with experience in care transitions preferred.
  • Experience with pediatric population a plus.
  • Strong understanding of healthcare systems, discharge planning, and care coordination principles.
  • Excellent communication, interpersonal, and organizational skills.
  • Ability to use clinical judgment to work independently and effectively collaborate with interdisciplinary teams.
  • Knowledge of community resources and support services, especially within the states of CT and MA.
  • Bilingual candidates are encouraged to apply.

Skills:

  • Care coordination and discharge planning
  • Patient education and advocacy
  • Strong communication and interpersonal skills
  • Problem-solving and critical thinking
  • Ability to work effectively in a fast-paced environment
  • Strong organizational and multitasking abilities
  • Knowledge of community resources
  • Proficiency with electronic medical records (EMR) and care management software, including Athena.
  • Proficiency with Microsoft 365, including Excel and Teams.

Work Environment:

  • The position typically operates in a remote setting that may require occasional travel to provider practice or corporate office.
  • The role may involve direct interaction with patients, families, and healthcare providers, requiring sensitivity and empathy.

PHYSICAL AND MENTAL REQUIREMENTS:

The Physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Regularly required to use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms; and talk or hear.
  • Frequently required to maintain a stationary position and move or traverse.
  • Occasionally required to stand; climb or balance; and stoop, kneel, crouch or crawl.
  • Ability to lift and/or move up to 20 pounds.
  • Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus.
  • The dexterity necessary to utilize a computer keyboard on a regular basis is essential.
  • Some travel may be required

ADDITIONAL REQUIREMENTS:

  • As a condition of employment at SoNE HEALTH, all employees must reside in New Hampshire, Rhode Island, Maine, Vermont, Connecticut, or Massachusetts.
  • For the safety and well-being of our employees, all employees are required to be fully vaccinated for influenza.
  • If you will be working in a remote or hybrid capacity, we require a stable internet connection. We recommend that you have an internet service provider with speeds of at least 30Mbps download/5Mbps upload.

ADHERENCE TO THE SoNE HEALTH CODE OF CONDUCT:

  • Code of Conduct: Employee will understand and follow the guidelines and standards outlined in the SoNE HEALTH Code of Conduct and demonstrate an understanding of the SoNE HEALTH Mission, Vision and Core Values.
  • Policies and Procedures: Employee will comply with all SoNE HEALTH policies and procedures relevant to their role, including those related to compliance, safety and confidentiality.
  • Regulatory Requirements: Employee will ensure actions and behaviors are in accordance with applicable laws, regulations, professional standards, policies, procedures and the Code of Conduct.