(RN) Transitional Care Coordinator

General Summary of Position

The Transitional Care Coordinator coordinates patient care and discharge planning across the continuum under the auspices of a provider's prescribed plan of care national guidelines and within the scope of case management practice. Educates and provides information and support to patients in order to guide and facilitate understanding of treatment plans prescribed by licensed independent practitioners and/or within scope of nursing/ social work /respiratory therapy practice. Oversees directs and provides holistic culturally competent and evidence-based care. Monitors patient outcomes and participates in quality improvement activities. Contributes to and collaborates with health care team members to positively impact patient outcomes and patient experiences. Is recognized as a professional role model and Case Management Care Co-ordination readmission prevention expert who promotes a professional environment that supports nursing/social work/ respiratory therapy excellence and collaborative shared decision making.

Primary Duties and Responsibilities

• Handles patient assessment education discharge planning and development of a post-acute care plan. Arranges and coordinates post-acute services and direct follow-up and monitoring patients' progress relative to their post-acute plan.
• Analyzes services and resources necessary to effectively prevent readmission and/or respond to the readmitted patients' episode of care encompassing the 30-day period post discharge from an inpatient stay.
• Works within the interdisciplinary team throughout the continuum of care to develop and manage the plan of care for the patient assisting patient/family with scheduling of ancillary testing and follow-up appointments; completing risk assessment screening and education regarding resources available to the patient and family/significant caregiver; and planning for continuing care such as but not limited to patient and community services community outreach resources home care palliative and hospice services as necessary.
• Provides patient education such as initial and follow-up continuing education related to specific disease process associated treatment modality management and agreed plan of care for patient and family; and is available as a resource to assist in the provision of community education and outreach development.
• Acts as a liaison between patients' families the health care team community resources and other facilities to coordinate the provision of post-acute care; and as a patient advocate to help identify and eliminate barriers to care. Ensures patients' referral process and transition into specialty services are timely and efficient anticipates patient and family needs throughout the continuum of care. Explores and connects patients with appropriate resources health care and support services within MedStar Washington Hospital Center at other external facilities and in their communities for timely diagnosis treatment and survivorship.
• Monitors patient progress goal attainment and patient experience feedback to evaluate the effectiveness of care. Ensures plan of care changes are communicated to patient family and team.
• Contributes to development of internal case management guidelines/pathways.
• Monitors patient outcomes and utilizes quality improvement activities and strategies that support quality patient care and optimizes outcomes in an interdisciplinary care environment and consistent with patient and family wishes.
• Research cause of all readmissions reevaluates discharge plan and works with the patient and family/support on needs of renewed discharge plan.
• Maintains a working knowledge of available clinical trials that might be appropriate to the patient population. Collaborates with research coordinators and/or principal investigators to ensure adherence to research protocols.
• Performs other duties and responsibilities that are appropriate to the position and area.

Minimal Qualifications
Education

• Bachelor's degree in Nursing required

Experience

• 3-4 years of progressively more responsible patient education and services coordination experience required

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia required or
• Professional Case Management certification preferred

Knowledge Skills and Abilities

• Ability to coordinate with multiple external agencies to support the patient/family in the community.