Transition Coordinator - LMH - Yale New Haven Health

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Functions as a member of the health care team and is responsible and accountable for ensuring appropriate transition of care from initial point of contact through discharge. This staff member is responsible to proactively plan and develop solutions to unique and complex discharge processes in collaboration with the Care Management staff and health care team. Interaction with both external vendors, insurance companies, all members of the health care team, and the patient/responsible party are primary to the functioning of this position. The action of these staff members directly impacts the ability to discharge patients in a timely and safe manner, which impacts the hospital LOS and the delivery of quality patient care. In collaboration with the Care Manager this staff member is responsible for the flow of patients throughout their service on a daily basis and all necessary follow-up. Patient and family centered care (PFCC) at YNHH is demonstrated by working with patients and their responsible party based on the 4 principles of PFCC: participation, dignity and respect, information sharing, and collaboration. This includes providing Service Excellence by creating a great First Impression by demonstrating exemplary customer service skills for all customer groups including patients, their responsible party, physicians, staff and support department personnel. Adheres to the I Am YNHH service excellence pledge and promotes a positive work environment.

EEO/AA/Disability/Veteran

• 1. RESPONSIBILITIES Coordinates placement of hospitalized patients with extended care facility, home care or other community based agencies and facilitates delivery of equipment and supplies as directed by Care Coordinator or Social Work partner. 1. Gathers appropriate information needed on patient and family upon referral, to achieve discharge plan as developed by RN/SW Care Coordinator partner. 1 .1 Contacts appropriate numbers (five) of nursing homes upon request for placement from Care Coordination staff as indicated by feedback from staff and supervisory observation . 1 .2 Contacts appropriate agencies upon receipt of request for discharge services from RN/SW Care Coordinator partner. 1 .3 Make additional referrals to agencies and facilities as needed to achieve discharge plan including referrals and obtaining authorization for dialysis treatment, transportation, home care and durable medical equipment as well as infusion therapy as requested by RN/SW Care Coordinator. 1 .4 1 .5 Provides feedback to Care Coordinator upon of receipt of material/information needed by agency. Coordinates with each Care Coordinator partner to monitor and prioritize the discharge plan for each patient on a regular basis as evidenced by supervisory observation. 1 .6 Insures all paperwork and electronic documentation needed to accompany patient at the time of patient's discharge is available and completed as evidenced by chart notes and supervisory observation. 1 .7 Confirms that all paperwork and documentation being sent to outside agency (ECF, VNA, etc.) ,is completed timely. This information includes, but is not exclusive of: X-rays, PT evaluations, medication list, labs, etc. 1 .8 Identifies all problems that cause delay or lack of timely discharge of patients and reports them to RN/SW CC partner or Director of Care Coordination. 1 .9 Maintains updated information on agencies, vendors and facilities through regular visits and contact with appropriate personnel as evidenced by supervisory observation. 1 .10 Assists with all departmental reports relating to discharge planning according to departmental policy as observed by supervisor. 1 .11 2. Maintains appropriate patient records as mandated by department and hospital policy. RESPONSIBILITIES Documents actions completed to achieve discharge plan as soon as possible but not to exceed 24 hours in the electronic medical record and Allscripts as determined by hospital standards . 2 .1 Maintains ambulance log on all discharges requiring ambulance or wheelchair assistance as observed by supervisor. 2 .2 2 .3 Maintains current knowledge of SDK to reference patient insurance information. 2 .4 Provides feedback on ambulance company performance to Director of Care Coordination. 2 .5 Submits statistical reports by established deadline as indicated by monthly log of reports. Performs activities in compliance with JCAHO and department standards as indicated by monthly random review of discharge planning materials. 2 .6 3. Maintains knowledge of trends and developments in the field of discharge planning. Attends and participates in in-service meetings and other designated training events that will enhance skills on a regular basis as documented by attendance at training seminars. 3 .1 3 .2 Recommends topics and speakers to department director for in-service meetings. Demonstrates and maintains current knowledge and skill in providing appropriate care for patients as observed by supervisor and as indicated by feedback from staff . 3 .3 Demonstrates and maintains current knowledge of third party payer contracts with extended care facilities and ambulance companies as observed by supervisor and as indicated by feedback from staff . 3 .4 3 .5 Assists in coordination of periodic meetings with local agencies (i.e ECFs, home care agencies, etc.).

EDUCATION

Associate Degree and/or Bachelor of Science Degree in Business Administration, Human Services, Health Administration or other health care related field preferred. A combination of education and experience may be substituted at the discretion of Care Management leadership and compensation.

EXPERIENCE

Two (2) to three (3) years of experience in a healthcare environment is required.

LICENSURE

n/a

SPECIAL SKILLS

Must be organized, able to prioritize and balance competing tasks working with many different individuals. Must be able to communicate and resolve issues. Self-direction and ability to proactively anticipate workload is imperative. Must be able to utilize the computer for Outlook communication, website research, excel spreadsheets, and faxing.