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The Care Transitions Team RN (CTT) serves as the patient care liaison coordinating services throughout the continuum of care to improve quality, reduce avoidable readmissions and reduce health care costs.
The CTT's will follow patients from admission of an acute care stay throughout transition to the post-acute setting.
The Care Transitions program collaborates with an interdisciplinary care team working adjunct to acute care Case Managers and post-acute designated personnel.
The CTT works with interdisciplinary teams to ensure patient needs are identified and services are initiated once the patient transitions from the acute care setting.
If additional necessities arise once the patient is discharged, the CTT will coordinate appropriate services resolving any patient needs.
Pay Range: $28.
71-$48.
77
Employment Type: Part time, 40 hours every two weeks.
NO weekends.
NO holidays.
Schedule: Variable, Monday -Friday 8am-4:30pm
Patient Identification and Risk Assessment Uses the Cerner Readmission Prevention tool to identify appropriate patients for Care Transitions.
Provides coordination of care services as patients' transition through the care continuum per transition protocols.
Effectively documents in the EMR designated Transitions Readiness screens to facilitate appropriate identification of readmission risk.
Using this data, forms an appropriate transition plan spanning the 30 days post acute care discharge.
• Planning and Coordination Collaborates with interdisciplinary teams including but not limited to Care Management, Hospitalists, pharmacy, Physician Practices,post-acute services and inpatient interdisciplinary team to maximize clinical quality outcomes.
Serves as a liaison for case updates and collaborates with post-acute providers identifying appropriate level and site of care and utilization of post-acute services.
Acts as a liaison/coordinator with post-acute services monitoring progress of care and facilitating transition to subsequent levels of care as appropriate, ensuring warm hand-offs.
Collaborates with the patient and family to establish Physician follow-up visits within 7-14 days of acute care discharge to home.
For patients transitioning to the post-acute setting, coordinate physician follow-up appointments after discharging from the SNF.
Provide telephonic transition with patient post discharge to home with intensive coordination of care triage 24 hr initial follow-up call to include medication reconciliation, symptom specific related questions to diagnoses and chronic disease, follow-up appointments made and attended, assess for potential needs, identify and resolve issues.
Continue telephonic transition per protocol and as needed.
Provide face to face contact with identified patients at admission and prior to discharge of their acute care admission.
Provide a summary of care to the PCP within 48 hours of discharge and at the hand-off of the patient after the 30 day period.
• Programmatic Improvement Investigates with patient to identify reasons for hospital admission/readmission and identify the need to prevent an unnecessary readmissions.
Investigates the root cause on readmissions within 30 days of acute care discharge.
Identify trends or patterns among post-acute partners that impede a patient's successful transition and create/coordinate a process for optimal hand- off among acute care discharges, post acute transitions and home.
Holland Hospital is an Equal Opportunity Employer, please see our EEO policy
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