Transitional Care Coordinator

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Department:
Transitional Care

The Transitional Care Coordinator (TCC) is responsible for proactively coordinating and assisting with transitioning medically complex patients from the hospital to home.

The TCC will work with the high risk patients to optimize recommendations to ensure continued health with the goal of preventing readmission.

In collaboration with the physician, hospital care teams and family/significant others, the TCC will assess evaluate, and implement a plan of care for the patient.

The TCC works collaboratively with the Transitional Care Program Manager, Transitional Care Social Worker, Case Management staff and other members of the Multidisciplinary team to develop a Continuum of Care plan to assure patients have the resources and instructions to carry out their Plan of Care safely.

The TCC will follow up with the patient and patient support structure to ensure compliance with the medical treatment plans.


* Prior to discharge meets with all patients that meet criteria and assigned to Transitional Care Program.


* Introduces self, program, and identify immediate barriers/needs to outpatient care/support.


* Calls patients in the disease specific programs as well as the High Risk program 24-48 hours post discharge to identify any barriers to success in the discharge plan.

Facilitates resources as needed.


* Utilizes the call-back script on all assigned patients, and documents accordingly.


* Serves as a resource and educator to the patient and her/his family for a minimum of 30 days post discharge.


* Intervenes on the behalf of the patient and organization to reduce avoidable emergency room visits or hospital admissions.


* Provides disease specific patient education including medication as needed.


* Evaluates aspects of each patient's condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication-self management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags.


* Serves as a guide to the patient, coaching the patient in addressing critical issues and self-management tasks rather than directly taking over and providing care.


* Documents call backs and care plans in the Meditech/Allscripts.


* Facilitates follow-up appointments with PCP and Consultants as needed.


* Collaborates closely with the Transitional Care Program Manager and Transitional Care Social Worker when barriers are identified and action is needed.

Education: A minimum of an Associate Degree in nursing (AND) required.

Bachelors of Science in Nursing (BSN) preferred.

Licensure: Current California Registered Nurse license required.

Current BLS/Healthcare Provider status as per American Heart Association st...