Full Job Description
The Transitional Care Coordinator coordinates patient care and discharge planning across the continuum under the auspices of a provider's prescribed plan of care, national guidelines, and within the scope of case management practice. Educates and provides information and support to patients in order to guide and facilitate understanding of treatment plans prescribed by licensed independent practitioners and/or within scope of nursing/ social work /respiratory therapy practice. Oversees, directs, and provides holistic, culturally competent and evidence-based care. Monitors patient outcomes and participates in quality improvement activities. Contributes to and collaborates with health care team members to positively impact patient outcomes and patient experiences. Is recognized as a professional role model, and Case Management Care Co-ordination readmission prevention expert who promotes a professional environment that supports nursing/social work/ respiratory therapy excellence and collaborative shared decision making.
Bachelor’s degree in Nursing, or Master’s degree in Social Work, or Associate’s degree in Respiratory Therapy is required.
Approximately three to four years of progressively more responsible patient education and services coordination experience. Ability to coordinate with multiple external agencies to support the patient/family in the community.
On The Job Experience
Approximately six to twelve months to gain familiarity with the hospital environment, department routines and procedures, and the full range of job duties.
Licensure as a Registered Nurse (RN), or Independent Clinical Social Worker (LICSW), or Respiratory Care Practitioner in the District of Columbia. The Respiratory Care Practitioner must also be credentialed as a Registered Respiratory Therapist by the National Board for Respiratory Care (NRBC). Professional Case Management certification is preferred.
Knowledge, Skills & Abilities
PROBLEM SOLVING: Job requires a very high level of problem-solving.
INTERNAL CONTACTS: Internal contacts necessary to effectively advise, consult or counsel others to gain cooperation and acceptance of ideas or actions.
INDEPENDENT JUDGMENT: Work activities are performed independently, utilizing basic guidelines as standards of performance. Advice and guidance may be sought from the members of the department’s management team as warranted to ensure the provision of quality care.
Primary Duties and Responsibilities
Handles patient assessment, education, discharge planning, and development of a post acute care plan. Arranges and coordinates post-acute services, and direct follow-up, and monitoring patients’ progress relative to their post-acute plan.
Analyzes services and resources necessary to effectively prevent readmission and/or respond to the readmitted patients’ episode of care encompassing the 30 day period post discharge from an inpatient stay.
Works within the interdisciplinary team throughout the continuum of care to develop and manage the plan of care for the patient, assisting patient/family with scheduling of ancillary testing and follow-up appointments; completing risk" assessment screening and education regarding resources available to the patient and family/significant caregiver; and planning for continuing care such as, but not limited to, patient and community services, community outreach resources, home care, palliative, and hospice services as necessary.
Provides patient education such as initial and follow-up continuing education related to specific disease process, associated treatment modality, management, and agreed plan of care for patient and family; and is available as a resources to assist in the provision of community education and outreach development.
Acts as a liaison between patients, families, the health care team, community resources and other facilities to coordinate the provision of post acute care; and as a patient advocate to help identify and eliminate barriers to care. Ensures patients' referral process and transition into specialty services are timely and efficient, anticipates patient and family needs throughout the continuum of care. Explores and connects patients with appropriate resources, health care and support services within MedStar Washington Hospital Center, at other external facilities, and in their communities for timely diagnosis, treatment, and survivorship.
Monitors patient progress, goal attainment and patient experience feedback to evaluate the effectiveness of care. Ensures plan of care changes are communicated to patient, family, and team.
Contributes to development of internal case management guidelines/pathways.
Monitors patient outcomes and utilizes quality improvement activities and strategies that support quality patient care and optimizes outcomes in an interdisciplinary care environment and consistent with patient and family wishes.
Researches cause of all readmissions, reevaluates discharge plan, and works with the patient and family/support on needs of renewed discharge plan.
Maintains a working knowledge of available clinical trials that might be appropriate to the patient population. Collaborates with research coordinators and/or principle investigators to ensure adherence to research protocols.
Performs other duties and responsibilities that are appropriate to the position and area.
Location: MedStar Washington Hospital Center · Utilization-Clin Rsrc Mgt
Schedule: Full Time, Day Shift with rotating weekend