Senior Transitions Health Caoch - Great Lakes Behavioral Research Institute/Diversified Care Management

Summary
The Senior Transitions Health Coach provides thirty-day interventions to targeted patients who are recently hospitalized.  The primary role is to identify eligible clients, provide specialized intervention with the goal of preventing avoidable hospitalizations and to empower patients to be the leaders in their healthcare.  To accomplish this, Incumbent will function as an information and referral source, provide a thirty-day intervention to patients and work with hospitals and health plans to prevent readmissions. The Senior Health Coach works as a member of the multidisciplinary health care team to assure that discharge planning critical paths are followed, providing for successful care transitions. The Senior Health Coach will work on high-risk cases, conduct assessments, assist with training new staff and coordinate planning with the Healthcare Provider.

Essential Duties and Responsibilities

• • • Interacts with designated AAA staff, hospital staff and participants when active patients are admitted into the hospital.
    • Consults with hospital discharge planner, physicians and multidisciplinary teams to identify patients who would benefit from the Program.
    • Conducts assessments of need for community-based service and support and provides referrals.
    • Actively consults and collaborates with hospital multidisciplinary team in planning and executing patient transitions.
    • Actively engages patients and caregivers in the discharge planning process using valid and reliable instruments; including a discharge preparation checklist, personal health record, medication reconciliation process and plan for medical follow-up.
    • Directs engagement with patients and caregivers to complete the discharge preparation checklist, personal health record, medication reconciliation, as well as identification of educational needs in chronic disease process and self-management skills.
    • Visits patient daily at hospital to ensure that patient and family are fully engaged and prepared for care transition process, including necessary tools and competency in self-management skills.
    • Provides additional coaching and education as necessary to assure transition is executed consistent with patient and caregiver goals.
    • Visits patient within 48 hours of transition to home or other care setting to review care transition process including adherence with discharge preparation checklist, evaluation of self-management skills, medication reconciliation, caregiver knowledge and self-management skills.  Recognizes and addresses red flags and plans for medical contact and follow-up.
    • Establishes an ongoing plan for home visits and phone contacts specific to patient’s needs.
    • Tracks program and individual performance objectives and routinely reports on progress and outcomes.
    • Actively participates in readmission reviews with hospital staff and health plans.
    • Attends staff meetings and meets with supervisor regularly.
    • Works directly with Care Management at hospitals and health plans to coordinate care. 
    • Conducts health risk assessments for the payors.
    • Assists with the training of new staff.
    • Assists Supervisor with exploring trainings for staff meetings.
    • Shares resources at team meetings.
    • Assist in pilots.

Supervisory Responsibilities
This job has no supervisory responsibilities.

Additional Responsibilities
From time to time the employee will be required to perform additional tasks and duties as required by the employer.    

Knowledge, Skills and Abilities

• Ability to apply various coaching methodology to cases.
• Strong understanding of a coaching model and the ability to train others in this discipline. 
• Ability to interact and engage with participants/family members/caregivers/direct care workers.
• Demonstrated organizational skills.
• Ability to work independently with minimal supervision.
• Proficiency in Microsoft Office products.
• Ability to work non-traditional hours, as needed.
• Knowledge of geriatrics, home and community-based services and social services preferred.
• Working knowledge of chronic disease self-management.
• Experience participating on a multi-disciplinary health care team.
• Experience working with chronically ill patients to identify patient goals and outcomes and provide education necessary for patient self-management.
• Strong time management skills and ability to balance multiple responsibilities.
• Strong communication skills and ability to work collaboratively with other health care professionals to assure coordination and continuity of patient care.

Education/Experience Requirements
Bachelor’s degree, plus 2 years or more experience in transition coaching.
-OR-
Any equivalent combination of education and experience that meets the required knowledge, skills and abilities.

Salary
$45,000

Certificates, Licenses, Registrations
Act 33, 34 and FBI clearances
-AND-
Screening for debarment prior to hire and monthly during employment through both the Office of Inspector General and System for Award Management databases.
-AND-
Valid driver’s license and access to a reliable vehicle.

Above statements are intended to describe the general nature and level of work being performed by people assigned to this job and are not an exhaustive list of all duties and responsibilities associated with the job. 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions, consistent with applicable law.
 

AN EQUAL OPPORTUNITY EMPLOYER - M/F/V/D

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