Facility: Spalding Medical Center

Job Summary:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways: To assert a more active role during discharge and transitions of care from one setting to another. To develop lasting self-management skills. Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment. Oversight of medication management process, including the patient's ability to pay for medications and providing adequate support with obtaining medication prior to discharge.

Core Responsibilities and Essential Functions:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways: - To assert a more active role during discharge and transitions of care from one setting to another. - To develop lasting self-management skills. - Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment. - Oversight of medication management process, including the patient’s ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways: - To assert a more active role during discharge and transitions of care from one setting to another. - To develop lasting self-management skills. - Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment. - Oversight of medication management process, including the patient’s ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways: - To assert a more active role during discharge and transitions of care from one setting to another. - To develop lasting self-management skills. - Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment. - Oversight of medication management process, including the patient’s ability to pay for medications and providing adequate support with obtaining medication prior to discharge.

Required Minimum Education:

Graduate of an accredited school of Practical Nursing. Required

Required Minimum License(s) and Certification(s):

Lic Practical Nurse 1.00 Required Basic Life Support 2.00 Required BLS - Instructor 2.00 Required BLS - Provisional 2.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Previous experience with patient coaching Required

Required Minimum Skills:

Excellent written and verbal communication skills, proficient in Microsoft Office Suite Products, ability to lead and organize meetings, ability to present in groups, Strong ability to multitask, work in a fast pace environment and implement change, ability to collect, analyze and present data.