Identifies patients with high risk conditions for readmission (through Cerner software) and facilitates decision making and communication to ensure resolution of care issues and comprehensive discharge planning. (heart failure, pneumonia, acute myocardial infarction, COPD, Total Joint Procedures)
Educates and coaches patient and families in disease self-management both during the hospital stay and post discharge. (coordination with nursing and physicians) - patient population identified in #1.
Reinforce medication education given by nursing, pharmacy and physician for population identified in #1.
Coordinate care of patients at risk for readmission from admission through 30 days post-discharge for the patient population identified in #1. Promotes and evaluates the effective utilization of resources using current clinical knowledge and awareness of community services.
Provide telephone reinforcement of the discharge plan and problem solving after discharge. Reinforce education with the patient/family on plan of care and expected outcomes. Document in the electronic patient record (readmission software in Cerner).
Reviews and analyzes adherence with readmission metrics for Florida Hospital Waterman. Follow up on monthly reports as needed.
Participates in readmission meetings and webinars. Assists in education of other hospital staff concerning readmissions.
Demonstrates knowledge of the principles of growth and development over the life span with the ability to interpret the appropriate information needed for the patient’s age-specific needs.
Exhibits critical thinking skills, organizational skills, flexibility, and time management.
Knowledge of disease management in acute and post-acute settings
Demonstrates effective interpersonal and communication skills
Demonstrates tact, diplomacy, negotiation skills and customer relations.
Ability to work independently while collaborating with other team members.
What You Will Need:
Florida licensed RN
Minimum of 3-5 years of clinical experience in an acute hospital setting
State of Florida Nursing License (RN)
Computer proficiency required including MS-Outlook, Excel, keyboard skills, knowledge of electronic medical record
Ability to apply creative problem solving skills
Under general supervision by the supervisor of case management, the transitional care coordinator (TCC) is responsible for following the high risk Medicare patients for readmissions as determined by Medicare rules and regulations. The TCC in partnership with patients, caregivers, physicians and the multidisciplinary team utilizes professional skills to reduce unnecessary readmissions through a comprehensive transition of care program utilized by Adventist Health Care Systems (AHS). This position is responsible to: assess patient and caregivers for care coordination, medical, discharge and psychosocial needs; coach patients and families in disease self-management and establish plans for safe and effective transfers in the movement of patients across the continuum of care. The TCC supports the mission of Florida Hospital Waterman and complies with the AHS code of conduct.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.