Transition Coach

AgeSpan

Formerly Elder Services of the Merrimack Valley/North Shore

About Us: Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place

At AgeSpan, you'll find a work environment that combines:

• A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds.
• A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions.
• Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills.
• A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs.

Depending on your role and your hours, we offer

• Flexible schedule and hybrid work opportunities
• Competitive salaries
• Healthcare (medical, dental)
• 403b Retirement Plan with agency match
• 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays
• Social Work Licensing Program
• License Renewal Paid by agency for RN's and Social Workers
• Mileage reimbursement
• Free parking
• Employee Referral Bonuses
• Employee Assistance Program
• Tuition Remission Program
• Agency subsidized gym membership (on-site in Lawrence)
• Commitment to promoting within

Position Responsibilities: The Transition Coach is key to ensuring safe and effective transfers in the movement of patients throughout the care continuum, serving as the bridge between the professional staff in a care setting (ie hospital, nursing home) and the patient and or family. The Transition Coach provides resources and support to the patient and or family for an effective care transition, improved self-management skills, enhanced patient-practitioner communication and avoiding preventable rehospitalizations.

Essential Functions:

• Participates in Coleman training and orientation sessions as assigned.
• Provides telephonic outreach to patients to arrange in-home visit. For patients agreeing to participate, provides each patient with a minimum of one in-home in-person visit within seven (7) days of referral utilizing the Coleman Care Transitions model.
• Conducts two (2) to three (3) additional follow up phone calls to the patient within the 30 days post emergency room visit emphasizing the elements discussed in the previous in-home in-person visit.
• In accordance with the Coleman Care Transitions Intervention Model, the coach will:
  • Provide care transition intervention activities in the following domains: medication self management, personal health record, post-hospitalization physician follow-up, and knowledge of red flags.
  • Maintain a supportive relationship to empower each patient to better manage their health and reach their personal goal.
  • Encourage conversations about advance directives with patients and caregivers.
  • Prepare and submit timely and accurate documentation on interventions.

• Identifies required support services and provides to the patient as appropriate.
• Identifies unmet community needs and provides referrals and resources as appropriate.
• Participates in weekly meetings with clinical staff to discuss the status and progress of enrolled patients.
• When appropriate, requests a 60- or 90-day extension of patient's participation in the Transition In Care (TIC) program.
• Communicates/coordinates activities with other AgeSpan staff including I&R, case managers, social workers, and nurses. As indicated, communicate with VNA and/or physicians regarding patients' discharge and post-discharge needs.
• Documents activities in journal notes, medical records, and Transition in Care database as appropriate.
• Completes all documentation required for measuring quality and outcomes.
• Meets monthly targets including enrollments.
• Maintains confidentiality with all aspects of information in accordance with AgeSpan policy.
• Maintains positive relationships with all customers including but not limited to patients, hospital staff and care transition team.
• Administers functional assessments as indicated.
• Reinforces patient education in patients learning style and health literacy in order to provide education on the appropriate level.
• Communicates with the patient and family to ensure understanding when treatment and care recommendations are determined.
• Assesses level of understanding of medications, discharge instructions, and plan of care with patient and informal support system.
• Confirms available transportation for appointments with primary care physician.
• Assists with the implementation and/or referral to special classes and events related to care of patient with chronic illnesses. ie. Chronic Disease Self Management Programs.
• Acts as a liaison with home care and primary care physician as needed to prevent re-hospitalization.
• Other duties as indicated and assigned.

Qualifications: BA/BS in social work, human services or related field required; experience with elders preferred; Associate degree with significant relevant work experience may be substituted for portion of degree.

Strong written, verbal, organizational and computer skills required. Knowledge of the long-term care and social service delivery systems, community resources and the local service systems for elders and persons with disabilities preferred.

Must successfully pass the background check required by the contracting agency. Must be willing to obtain all immunizations if required by the hospital/contract. Reliable transportation and valid driver's license required as field work is an essential component of the position.

Hours: 37.5 per week

AA/EOE

AgeSpan is strongly committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. It is important that our employees reflect the diverse communities we serve. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work-life balance.