Care Transitions 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.
- Explain the Care Transitions Intervention® (CTI®)to the patient and obtain signed, informed Consent.
- Assess the patient’s baseline activation level for self-care through use of the Patient Activation Measure (PAM).
- Perform the facility visit, developing the coaching relationship, empowering the patient to take an active, informed role in their discharge planning and introducing the patient-centered personal health record.
- Perform the home visit by the next business day after discharge, identifying the patient’s biggest health concern and the patient’s immediate goals for recovery, and coaching the patient through the patient-centered personal health record and all four pillars. Role-play interactions with providers as appropriate.
- Perform three follow-up phone calls to the patient, on or about days two, seven and fourteen after discharge.
- Track coach-related metrics and report on intervention progress.
- Direct all urgent /extraordinary requests or incidents to appropriate staff.
- Bachelor’s degree in health care field. Master of Social Work preferred.
- Work experience in a health care setting preferred.
- Ability to commit to implementing CTI® with patient population within one to two months 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 set up a home office with internet, computer, etc.
- 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.
- This is a contract position withRegional HealthPlus in Spartanburg, SC
- The majority of all work will bedone within Cherokee County
- Coaching typically takes placeMonday through Friday, between the hours of 8:00am and 5:00pm. Weekend hours area possibility.
- Coaches must have the ability totelecommute and be onsite during the work week.
All interested candidates, please email your cover letter and resume to: Holly Becker
Hbecker@srhs.com by August 15