Home Health Care Transition Coordinator

OhioHealth at Home in partnership with Compassus Position Summary The Home Health Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. They uphold the Code of Ethical Conduct, promote positive working relationships within the company, among all departments, and with all external stakeholders. They serve as a trusted resource for the physician and hospital case managers and communicate with referral sources. They conduct skilled conversations with physicians, patients, families, and healthcare providers and maintain an understanding of hospital and post-acute healthcare systems. They navigate getting patients into the right care at the right time. Position Specific Responsibilities Meet regularly with physicians in the hospital to discuss specific patients, give guidance and provide an understanding of post-acute service support, ensuring continuity of care as a priority. Act as hospital case managers (rounding or interactions in step with the hospital): high-risk patient reviews. Support transition to home health, home infusion, and hospice services by conducting in-person bedside transitions where services are offered. Educate on hospice, home infusion, and home health benefits to patient families and referral sources. Develop genuine collegial relationships with other Ascension professionals and identify times to meet regularly with clinicians to problem-solve and review cases. Understand how to interact with difficult patients/families. Identify steps to having a successful family meeting. Develop communication skills to support patients/families with difficult discussions or differing points of view. Maintain a current list of admission coordinators for each healthcare service line. Align recommendations between patient/family and primary care team: Identify patient preferences/needs. Identify patient’s post-acute care needs. Confirm the level of care most appropriate for the patient - right care, right time. Educate patient on Homebound criteria and verify patient meets this requirement. Facilitate transition-to-home planning, including assessing post-discharge needs and developing and implementing a transition-to-the-home plan. Set patient-centered goals and facilitate transitions: Understand how to identify patient/family-specific treatment goals. Arrange for home admission - communicate with the Home Health and Home Infusion team(s). Coordinate patient care by obtaining H&P, physician orders, hospital records, and face-to-face documentation promptly. Verify patient demographic information is correct. Coordinate organization of transfer orders; educate patients on home care orders and home care services. Identify primary care physician to follow the plan of care. Conduct follow-up on re-hospitalized home health patients. Participate in home health re-hospitalization mitigation strategies – be a member of the strategy team. Develop ability to understand and digest claims data, and use of predictive analytics. Ensure excellent customer service to maintain and grow the business in the identified key accounts. Consistently work to improve personal knowledge and sales skills to become of greater value to our most important customers and the company. Meet or exceed assigned quotas, thereby maintaining and constantly improving the HH's competitive position. Perform other duties as assigned. Education and/or Experience Bachelor’s degree preferred. Two (2) to three (3) years of nursing experience as an RN preferred. Hospital and/or long-term care clinical experience highly preferred. Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, introduction to end-of-life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, and estimating and communicating prognosis/disease trajectory preferred. Skills Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage. Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications. Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Certifications, Licenses, and Registrations Active and unencumbered Registered Nurse license in the state(s) of employment preferred. Physical Demands and Work Environment The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization. EEO Statement At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Compassus Advantage Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter. Career Development: Access leadership pathways, mentorship, and personalized professional development. Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care. Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being. Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication. A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion. #J-18808-Ljbffr OhioHealth at Home