As a member of the Transitional Care team, the Transitional Care Coordinator (TCC) will function as the key patient advocate as it relates to coordination of post-acute care needs across all service lines--home health, home medical equipment, home infusion, hospice and palliative care, and other health system resources. As a hospital based resource, the TCC collaborates with all hospital departments to coordinate the most efficient transition of care for the patient. This is a mobile experience that primarily sits at West Penn Hospital.
- Care coordination and discharge planning -- responsible for identifying all post-acute care needs for patients and collaborating with the patient's caregiver team and Case Management staff, as well as internal (Healthcare@Home) and external service providers/agencies; lead/attend daily huddles or rounds at hospital as assigned; ensure patient's prescribed plan of care is executed at time of discharge to transition care to either in-network AHN (Healthcare@Home) service providers or external partner agencies.
- Assess patients' post-acute care needs in collaboration with interdisciplinary care team, patient, and family or caregiver.
- Bedside education -- provide bedside visits with patients, families, and caregivers to discuss transition of care plans and services; expectation is minimum of two visits--(1) for general introduction, and (2) for confirmation of post-acute care services and specialty education as needed.
- Referral completion -- collaborate with PTC team to ensure all required documentation for an accurate and complete referral is collected and provided to ensure seamless transition of care to post-acute service provider(s); responsible for documenting post-acute care arrangements, education, or other transitions in the appropriate software platform to promote a smooth transition of care.
- Case management - In conjunction with Case Management staff, serve as liaison and patient advocate on difficult cases (e.g., clinical complexity, socioeconomic issues, patient safety concerns, etc.); proactively collaborate with AHN and non-AHN post-acute service providers to ensure best possible outcome for patient and other stakeholders.
- Infusion hookups and education.
- Within hospital campuses, serve as liaison and customer support representative to ancillary departments, clinics, offices, etc., whose patients may benefit from coordinated post-acute care; advocate for all AHN Healthcare@Home programs and services.
- Responsible for discipline-specific professional development, licensure, and certification.
- Other miscellaneous duties as assigned (e.g. participation in interdisciplinary process improvement efforts, development of documentation templates and hand-off workflows to assure safe and effective care transitions).
- Valid PA Registered Nurse license
- Bachelor’s degree
- Post acute care experience
- 1-3 years experience as marketing or liaison for home health, hospice, HME, or infusion
- Valid PA driver’s license
- Oncology background
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