RN Transitional Care Coordinator-Elyria

Collaborates with all members of the health care team, patient and family (or significant others) to coordinate timely and efficient assessment of discharge planning needs and formulation of patient and family centered discharge plans.

What You Will Do

• Collaborates with the bedside nurse and clinical team, meets with patient and/or family to complete an initial discharge planning assessment within 24 hours of patient admission. 25%
  * Identifies patients and families with complex psychosocial, financial and legal discharge planning needs requiring a Social Work referral
• Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals 40%
  * Develops plans with attention to individual patient and family goals
  * Discusses estimated length of stay, treatment plan and discharge plan with attending physician and/or medical team
  * Ensures that the Interdisciplinary Care Plan and Discharge Plan are consistent with patient's clinical course, continued care needs and covered services
  * Refers to appropriate alternate site agency(s) based on post discharge needs and patient choice
  * Provides linkage to community resources and UH network services to facilitate optimal care, and serves as liaison to community agencies.
• Communicates/collaborates with the work team using a multidisciplinary approach. 20%
  * Provides guidance/consultation to peers/team regarding complex psychosocial and /or discharge planning issues/barriers.
  * Participates in Interdisciplinary Team rounding
  * Coordinates discharge teaching. Collaborates with bedside nurse and members of Interdisciplinary Team to support teaching efforts, with special attention to situations where patient and family education requiring teach back and show back are required
• Collaborates with Case Management/Utilization Review to clarify patient status, plan of care, barriers to discharge and discharge readiness 15%
• Ensures timely completion of discharge, transfer and/or referral forms and discharge order
• Regulatory: Coordinates activities to ensure patient's appeal rights under Notification of Hospital Discharge Appeal Rights

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.