Care Transitions Field Coach
The Care Transition Coach®, empowers the patient and/or family/caregiver to play an active and informed role in their health care. The Transition Coach® helps the patient to become good at, and comfortable with, managing their care after hospital discharge. The Transition Coach® provides guidance to the patient for effective care transitions, improved self-management skills and enhanced patient-provider communication. The Transition Coach® also facilitates interdisciplinary collaboration and care continuity across care settings. The Transition Coach® does not provide direct patient care or treatment.
· Coach the patient in building confidence and competence in four conceptual areas, or “pillars”: medication self-management, use of a patient-centered health record, primary care and Specialist follow-up and knowledge of red flags of their condition and how to respond.
· Be able to discuss the Upstate CareTransitions Program to family members and caregivers
· Conduct the home visit within 48-72 hours of discharge from facility.
· Complete a minimum of 3 follow-up phone calls over the 30 day period with the patient and/or caregiver.
· Introduce Personal Health Record (PHR) at home visit.
· Discharge Summaries with patients and caregivers.
· Evaluate current and any new medications the patient is on.
· Discuss the importance of understanding prescribed medications and having a system in place to ensure adherence to the regimen
· Facilitate appointment with either thePrimary Care Physician/Practitioner or treating specialist within 14 days of discharge
· Provide information and contact numbers for supplemental resources (transportation, non-clinical home care, meals, medication help, )
· Discuss any red flags and discuss how to respond appropriately.
· Track coach-related metrics and report on intervention progress.
· Direct all urgent /extraordinary requests or incidents to appropriate staff.
· Have the ability to meet all program metrics and standards.
· Any other duties as assigned.
· Bachelor’s degree in health care field. Master of Social Work preferred or Nursing Preferred
· Work experience in a health care or home health setting preferred.
· Ability to commit to implementing CTI® with patient population within one month after being trained.
· Ability to provide continuity to patients throughout the CTI® interactions.
· Ability to work independently with minimal supervision as well as part of a team.
· Exemplary customer service skills and ability to handle stressful situations with compassion and understanding.
· Ability to understand and operate a computer, copy machine and fax machine.
Ability to make mental and cultural shift from care provider to coaching paradigm, and able to adjust to associated process changes.
Ability to track and trend transition coach-related metrics and report on intervention progress.
Excellent verbal and comprehension skills.
Ability to maintain discretion with regard to patient information with absolute integrity.
TRAINING AND EDUCATION
On-the-job training provided by shadowing an experienced Coach and being shadowed by same.
On-going training and in-services as mandated by Supervisor.
Coaching typically takes place Monday through Friday, between the hours of 8:00 am and 7:00pm. Weekend hours are a possibility. Coaches must have the ability to telecommute and be onsite during the work week. Coach must be able and willing to travel to Spartanburg, Cherokee and Union Counties.
This is a contract position with Regional HealthPlus. Coaches are compensated on a per visit basis.
All interested candidates, please email your cover letter and resume to: Holly Becker