TRANSITION CARE COORDINATOR - Discharge Services

Legal Entity

Aultman Hospital

Position Summary

The Aultman Registered Nurse (RN) is a professional nurse that provides direct, primary nursing care to patients/residents. The RN delegates and coordinates patient care, based upon a documented assessment of the patient's/resident's needs. The RN supervises the care provided by individuals such as licensed practical nurses, patient care technicians/state tested nursing assistants/nurse aides, medical assistants, and etc., if applicable.

Department Summary

Serves as clinical liaison and encompasses coordination of care across the continuum for select populations including inpatient, to outpatient to community. The RN Care Coordinator (RN CC) is responsible for bridging the acute with the traditional episode, promoting positive and effective transition through modeling and facilitating new behaviors and self-management skills. The RN CC applies the process of assessment, planning, implementation, monitoring, evaluation, and coordination of care to meet the patients' health care needs across the continuum in collaboration with health care team members it ensures safe, quality, and cost-effective care. The RN-TCC must provide efficient, quality service always. The RN-CC will accomplish this goal by the timely coordination of quality healthcare services to meet an individual's specific health care needs in a cost-effective manner.

Qualifications

• Graduate of an accredited school of nursing; BSN preferred.

• Current, active licensure as a Registered Nurse through the Ohio Board of Nursing.

• Obtain and maintain current American Heart Association (AHA) training in Basic Life Support (BLS) utilizing Resuscitation Quality Improvement (RQI) is required.

• Certification preferred for RNs meeting applicable certification eligibility requirements.

• Membership in professional nursing organization preferred.

Department Qualifications

• Graduate of approved School of Nursing, BSN preferred

• Certification preferred or demonstrates willingness to become certified in Case Management or another appropriate professional specialty.

• Current licensure in the State of Ohio

• Five years' experience in clinical or outpatient setting with Case Management Experience

• Refined communication skills, both verbal and written

• Knowledge of managed care concepts in relation to financial aspects of patient care

• Refined organizational skills with well -developed style of diplomacy, assertiveness, and tolerance for ambiguity

• Refined negotiating skills and the ability to problem-solve and function autonomously

• Demonstrated ability to handle frequent interruptions in a courteous and professional manner.

• Demonstrates ability to effectively communicate with various customers.

• Demonstrates ability to work independently, and effectively perform multi-tasks.

• Demonstrates ability to utilize information systems within the scope of the position.

• Demonstrates ability to meet deadlines.

• Demonstrates ability to exercise independent decision-making capability.

• Demonstrates good organizational skills.

• Demonstrates ability to prioritize assignments.

• Able to cope with mental and emotional stressors of the position and deadlines.

• Functions independently with flexibility, integrity, and the ability to work effectively and efficiently with all levels of personnel.

• Possesses good interpersonal communication skills and works well with a diversity of co-workers.

• Displays professional manner and appearance, complying with the corporate dress code.

Skills

• Proficient computer skills to complete tasks as required.

• Must be organized, able to effectively prioritize tasks and exhibit appropriate time management skills.

• Must be detail oriented while focusing on safe practices and quality care.

• Demonstrates effective communication.

• Effective appropriate and professional interactions with colleagues/physicians, patients and visitors.

Department Skills

• Comfortable speaking to patients/families/physicians

• Detail oriented

• Communicate effectively

• Adaptability to changing work environment or needs

Responsibilities & Expectations

• RN applies the nursing process of assessment, planning interventions, accurately implements and/or delegates patient care, evaluates that care, and accurately communicates patient information in a timely manner.

• RN is a patient/resident advocate in conjunction with the other members of the healthcare team and fosters patient safety, comfort and satisfaction.

• Attains knowledge and competency that reflects current nursing practice.

• Demonstrates quality and effectiveness of nursing practice.

• Adhere to professional standards and guidelines, including ethical actions, relevant statutes, rules and regulations, during nursing practice.

• Collaborates with patient, family, and others in the conduct of nursing practice.

• Exhibits High Reliability Organization (HRO) tools and tones.

• Provides leadership in the professional practice setting and contributes to the professional development of peers, colleagues and students.

• Integrates research findings into practice.

• Responsible for timely review of emails, department communications and applicable learning assignments and completion as applicable.

Department Responsibilities & Expectations

• Collaborates with hospital care delivery team, Utilization Management and Social Workers as they identify patients at high risk for readmission to formulate plan of service and care across the continuum

• Oversees patient's clinical progress to ensure appropriate use of resources

• Responsible for oversight of discharge education

• Expedites proper sequencing and scheduling of interventions, treatments, and procedures in accordance with the patients' treatment plan and during inpatient and transition phases

• Meets with identified population to establish communication while in the acute setting and/or home setting to foster a relationship and promote goal setting throughout the entire episode of care

• Maintains active communication with patient as designated by health population management initiative, displaying a flexible and innovative approach to health management

• Promotes teaching and ensures understanding of disease process via teachback

• Promotes enhance patient -provider communication.

• Collaborate with all disciplines in the acute setting, to carry out ordered services

• Continues those efforts through active and ongoing communication with next level of care providers, supplying needed information, both written and verbal, to promote positive outcomes

• Functions as resource for patients regarding community outreach and support systems

• Continually works to update plans and interventions based on needs and dynamics surrounding changes in disease process, using evidence-based practice standards

• Promotes patient wellness through anticipating future needs, educating and referring to valid resources and supports

• Evaluate an investigate readmission data and causes

• Utilizes tracking tool for actions, interventions, and outcomes

• Monitors and generates reports on decided key indicators

• Actively participates in development initiatives that support the strategic plan for population health management

• Participates in regular department meeting forums

• Serves as formal link for next level providers, payers and works to negotiate resources and services

• Fosters role of advocacy promoting positive care outcomes in fiscally responsible manner

• Promotes patient wellness and facilitates healing
  • Practices Ethical Conduct:Demonstrates honesty and integrity in all functions and relationships
  • Maintains Aultman standards of confidentiality, including HIPAA privacy guidelines
  • Complies with policies and procedures always

• Meets acceptable attendance and punctuality expectations (excluding FMLA)

Working Conditions

• Meal and break times are coordinated with other staff members to maintain adequate coverage.

• Shifts are scheduled or changed due to the staffing needs of the unit/department based upon volume and acuity.

• Work weekends and holidays as assigned or as applicable based on department needs.

• Cross training depending upon department needs.

Department Working Conditions

• Hours of operation are 8:00 AM to 5:00 PM, Monday through Saturday, of which an eight-hour shift is assigned. Off Shift coverage as indicated. On-call hours to be assigned as appropriate.

• In Home Visits may be required

• Lunch and break periods must be coordinated with other staff members to maintain adequate office staffing during departmental operating hours.

• Sitting/standing/moving about intermittently during working hours.

• Subject to frequent interruptions and changes in priority of duties throughout the day.

• Works with highly confidential data, information, and situations.

Hazardous Exposure Category

Category I - Includes tasks that involve exposure to blood, body fluids, or tissues. All procedures or other job-related tasks that involve an inherent potential for spills or splashes of, or mucous membrane or skin contact with blood, body fluids or tissues are Category I tasks. Use of appropriate protective measures is required for every employee engaged in Category I tasks.

Demands

Frequency

Remarks

Lifting 0-10 lbs

Frequent 34-65%

Lifting 10-20 lbs

Frequent 34-65%

Lifting 20-35 lbs

Frequent 34-65%

Lifting 35-50 lbs

Occasional 10-33%

Lifting 50-75 lbs

Occasional 10-33%

Lifting 75-100 lbs

Occasional 10-33%

Lifting over 100 lbs

Occasional 10-33%

Forward Reaching

Frequent 34-65%

Overhead Reaching

Frequent 34-65%

Standing

Continuous 66% of the day

Walking

Continuous 66% of the day

Sitting

Occasional 10-33%

Climbing

Occasional 10-33%

Stairs/Ladder

Occasional 10-33%

Bending/Stooping

Frequent 34-65%

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Occasional 10-33%

Crawling

Never

Pushing/Pulling 0-10 lbs

Frequent 34-65%

Pushing/Pulling 10-20 lbs

Frequent 34-65%

Pushing/Pulling 20-35 lbs

Frequent 34-65%

Pushing/Pulling 35-50 lbs

Frequent 34-65%

Pushing/Pulling 50-100 lbs

Occasional 10-33%

Pushing/Pulling over 100 lbs

Occasional 10-33%

Carrying 0-10 lbs

Frequent 34-65%

Carrying 10-20 lbs

Frequent 34-65%

Carrying 20-35 lbs

Frequent 34-65%

Carrying 35-50 lbs

Occasional 10-33%

Carrying 50-100 lbs

Occasional 10-33%

Carrying over 100 lbs

Never

Grasping/repetitive sustained

Frequent 34-65%

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. The organization is an EEO/AA Employer M/F/Disability/Vet.

The organization will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on the organization or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the Aultman Human Resource Department and request such an accommodation.