- 07-Jun-2013 to 21-Jun-2013 (EST)
- Community Care Transitions Program
- Lawrence, MA, USA
- Full Time
The Community Care 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 and enhanced patient-practitioner communication.
• In accordance with the Coleman Care Transitions Intervention Model, the transition coach will:
o 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.
o Maintain a supportive relationship to empower each consumer to better manage their health and reach their personal goal.
o Encourage conversations about advance directives with patients and caregivers.
o Prepare and submit timely and accurate documentation on interventions
• Communicates with GSSC, United Health Care Plan RNs, case managers, social workers, nurses, ESMV Transition Coach, VNA and/or physicians regarding patients' discharge and post-discharge needs.
• Acts as a liaison with GSSC, United Healthcare Plan RNs, home care and primary care physician as needed to prevent re-hospitalization.
• Collaborates with Hospital Transition Care Coordinator to identify emergency room admissions that could use immediate interventions thus preventing unnecessary hospitalizations.
• Maintains positive relationships with all customers including but not limited to patients, hospital staff and care transition team.
• Administers functional assessments both in acute and community settings.
• Communicates with the patient and family 24-72 hours after discharge to clarify any outstanding concerns and ensure that the patient understands the importance of follow up care.
• Reinforces patient education in patients learning style and health literacy in order to provide education on the appropriate level.
• 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.
• Maintains confidentiality with all aspects of information in accordance with ESMV policy.
• Other duties as assigned.
BA/BS in social work, human services or related field required; experience with elders preferred; Associates Degree with significant relevant work experience may be substituted for portion of degree. Strong written, verbal, organizational, and computer skills required. Bilingual ability (Spanish, Khmer) preferred.
Salary: $16.06 per hour
Full Time: 37.5 hours per week
ALL CANDIDATES MUST SUBMIT BOTH A COVER LETTER AND A RESUME TO BE CONSIDERED.
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