Work whereevery momentmattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare network as a Transitional Care CoordinatorHartford HealthCare at Home the largest provider of homecare services in Connecticut has been fulfilling our mission for more than years Our Person Centered Care Model allows our employees to learn and grow within our organization all while providing integrated support to the patient As part of Hartford HealthCare we leverage cutting edge technology to provide quality care in our clientrsquos home Most importantly our employees are appreciated for the real differences they make in both the lives of their clients and their clientsrsquo familiesBasic Purpose of the PositionWork in collaboration with hospital case managers and or social workers skilled nursing facilities Assisted living facilities Independent Living Facilities home care agencies and physicians to provide education to customers patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patientrsquos transition across the post acute care continuum Serves as a bridge between the healthcare team and the patient andor caregivers as well as helps to reduce facility re admissions Provides information and guidance to the patient andor caregiver resulting in effective care transitions improved self management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referrals and building new clinical initiativesIn general most of the time will be spent in the following activities Strives to reach exceed corporate assigned admission goals for all service lines Building relationships and trust across the continuum Marketing HHCAH service lines for system and non system partners Identifying patients at risk during transition to home or SNF using standard tools of assessment Review demographic and clinical information and ensuring accuracy of information in the transitionfrom one setting to anotherChart review completed upon notification of the referral is as follows Review key information from EPIC hospital chart eg patient demographics history and physical exams comorbidities other hospital services received such as therapy and ongoing needs Identify DMEsupplies and company with contact information and document for HHCH team Identify criticalhigh risk medicationslabscare that need next day start of care and document for HHCH team Identify if patient has CCCI Agency on Aging WCAA CHCPE ICP Pro Health and or ACO services and document for HHCH team Communicate information that is essential in formulating an effective plan of care to HHCH staff in conjunction with supportive documentation Monitor all currentnew patients while at hospital SNF ALF and alert HHCH team when start of care will be needed Document currentnew HHCH patients that transition from acute setting to SNF with co TCC following up with SNF to capture that patient once short term rehab is completed Assist transitioning complex case high risk patients home in collaboration with Care Coordination hospital team patient family Conducting an ldquoat the bedsiderdquo meeting with the patient andor caregiver and following the patient during the post discharge transitional phase During Bedside visit Patient visual assessment education on disease process clinical review social review may be done Following up with the patient to ensure that the patient is following transitional plans and goals of careBedside visit may include but is not limited to Determine the patients language interpretation needs Identify skilled need and homebound status Identify location the patient will be receiving home care services Assessing patients health literacy and using teach back method as learning tool Identify primary caregiver with contact information including alternate contact information Identify high risk patients and or barriers to discharge Confirm patient has transportation to appointments Engage in attainable goals with holistic and sustainable plan to avoid readmissions Identify Physician most appropriate to sign home care orders and review importance of MDSpecialist follow up appointments Identify POA HCR COP COE prior to or during visit Legal representativeIdentify home care services and additional services warranted if applicable ie HOPE Hospice Independence at Home Center for Healthy Aging Healthy Minds Dementia Behavioral Health TCRN SNFPatientfamily education that we provide is as follows Introduce concept of home health services provide brief overview of agency Explain HHCH will be in contact within hours to schedule the first home care visit Discuss the patientrsquos personal goals explain HHCH team will assist and discuss detailed plan of care during SOC visit Educate patient and family members in disease management utilizing hospital educational materials teaching of RED FLAG signssymptoms and utilize teach back technique to validate patientcaregivers understanding Notify patientfamily of copay or other financial obligations as appropriate Ensure patient has HHCH TCCrsquos contact information for questions Attend family meetings as appropriate Identify solutions and advocate for resources including discussion on specialty services When applicable reviewing the hospital discharge summary and medication list with patientcaregivers and assuring the transitional care processes are implemented by engaging patients and care givers in health self management including medication management Initiating Personal Health Record and emphasizing patientsrsquo early recognition of health care risks and symptoms to achieve longer term positive outcomes and avoid adverse events such as re hospitalization Performing pre discharge patient and family assessment to determine understanding and acceptance of discharge plan and orders in conjunction with discharge planning staff to ensure a smooth transition homeFollow Up Case CoordinationSocial Services of health care services Daily collaboration with Care CoordinationSocial Services acute system non system acute rehab SNF and ALF SNF TCCs rotating schedule of their centers on activepotential referrals as needed Confirm if patient has been or is active with HHCH upon request Notify Care CoordinationSocial Services when pastactive patient hospitalized Collaborate with Care CoordinationSocial Services on discharge date after care needs equipment and pertinent information obtained during bedside visit Make recommendations to case management social worker hospitalists for post acute services for any patient Document patient information attained during bedside visit and case management collaboration for the clinical team Present HHCH Patient Care Form to patients that have proven compliance issues with specific details discussed prior to patientrsquos discharge TCCrsquos are available to Care Coordination for collaboration on all patients referred to or inquiring HHCAH Collaborating and communicating with Primary Care Providers and home care staff to insure continuity of medical care through follow up appointments Preparing and maintaining accurate patient records charts and documents to support sound medical practice Notifies appropriate hospital or physician personnel when patient is having difficulty following the transitional care program helps to identify and remove barrier to goal attainment and assists with intervention as needed Consistently communicates with HHCAH management to make sure all issues and problems are seamlessly handled so that both the patient and the SNFhospitalphysician are satisfied with the results and process Participating in case conferences and or rounds at the request of hospital andor community agency staff Providing consultation to hospital staff and or skilled nursing facilities on community resources and home care issues Adheres to the practice of confidentiality HIPAA and other statefederal regulations regarding patients families staff and the Agency Schedule education to our customers using appropriate HHCAH personnelWork whereevery momentmattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare network as a Transitional Care CoordinatorHartford HealthCare at Home the largest provider of homecare services in Connecticut has been fulfilling our mission for more than years Our Person Centered Care Model allows our employees to learn and grow within our organization all while providing integrated support to the patient As part of Hartford HealthCare we leverage cutting edge technology to provide quality care in our clientrsquos home Most importantly our employees are appreciated for the real differences they make in both the lives of their clients and their clientsrsquo familiesBasic Purpose of the PositionWork in collaboration with hospital case managers and or social workers skilled nursing facilities Assisted living facilities Independent Living Facilities home care agencies and physicians to provide education to customers patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patientrsquos transition across the post acute care continuum Serves as a bridge between the healthcare team and the patient andor caregivers as well as helps to reduce facility re admissions Provides information and guidance to the patient andor caregiver resulting in effective care transitions improved self management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referrals and building new clinical initiativesIn general most of the time will be spent in the following activities Strives to reach exceed corporate assigned admission goals for all service lines Building relationships and trust across the continuum Marketing HHCAH service lines for system and non system partners Identifying patients at risk during transition to home or SNF using standard tools of assessment Review demographic and clinical information and ensuring accuracy of information in the transitionfrom one setting to anotherChart review completed upon notification of the referral is as follows Review key information from EPIC hospital chart eg patient demographics history and physical exams comorbidities other hospital services received such as therapy and ongoing needs Identify DMEsupplies and company with contact information and document for HHCH team Identify criticalhigh risk medicationslabscare that need next day start of care and document for HHCH team Identify if patient has CCCI Agency on Aging WCAA CHCPE ICP Pro Health and or ACO services and document for HHCH team Communicate information that is essential in formulating an effective plan of care to HHCH staff in conjunction with supportive documentation Monitor all currentnew patients while at hospital SNF ALF and alert HHCH team when start of care will be needed Document currentnew HHCH patients that transition from acute setting to SNF with co TCC following up with SNF to capture that patient once short term rehab is completed Assist transitioning complex case high risk patients home in collaboration with Care Coordination hospital team patient family Conducting an ldquoat the bedsiderdquo meeting with the patient andor caregiver and following the patient during the post discharge transitional phase During Bedside visit Patient visual assessment education on disease process clinical review social review may be done Following up with the patient to ensure that the patient is following transitional plans and goals of careBedside visit may include but is not limited to Determine the patients language interpretation needs Identify skilled need and homebound status Identify location the patient will be receiving home care services Assessing patients health literacy and using teach back method as learning tool Identify primary caregiver with contact information including alternate contact information Identify high risk patients and or barriers to discharge Confirm patient has transportation to appointments Engage in attainable goals with holistic and sustainable plan to avoid readmissions Identify Physician most appropriate to sign home care orders and review importance of MDSpecialist follow up appointments Identify POA HCR COP COE prior to or during visit Legal representativeIdentify home care services and additional services warranted if applicable ie HOPE Hospice Independence at Home Center for Healthy Aging Healthy Minds Dementia Behavioral Health TCRN SNFPatientfamily education that we provide is as follows Introduce concept of home health services provide brief overview of agency Explain HHCH will be in contact within hours to schedule the first home care visit Discuss the patientrsquos personal goals explain HHCH team will assist and discuss detailed plan of care during SOC visit Educate patient and family members in disease management utilizing hospital educational materials teaching of RED FLAG signssymptoms and utilize teach back technique to validate patientcaregivers understanding Notify patientfamily of copay or other financial obligations as appropriate Ensure patient has HHCH TCCrsquos contact information for questions Attend family meetings as appropriate Identify solutions and advocate for resources including discussion on specialty services When applicable reviewing the hospital discharge summary and medication list with patientcaregivers and assuring the transitional care processes are implemented by engaging patients and care givers in health self management including medication management Initiating Personal Health Record and emphasizing patientsrsquo early recognition of health care risks and symptoms to achieve longer term positive outcomes and avoid adverse events such as re hospitalization Performing pre discharge patient and family assessment to determine understanding and acceptance of discharge plan and orders in conjunction with discharge planning staff to ensure a smooth transition homeFollow Up Case CoordinationSocial Services of health care services Daily collaboration with Care CoordinationSocial Services acute system non system acute rehab SNF and ALF SNF TCCs rotating schedule of their centers on activepotential referrals as needed Confirm if patient has been or is active with HHCH upon request Notify Care CoordinationSocial Services when pastactive patient hospitalized Collaborate with Care CoordinationSocial Services on discharge date after care needs equipment and pertinent information obtained during bedside visit Make recommendations to case management social worker hospitalists for post acute services for any patient Document patient information attained during bedside visit and case management collaboration for the clinical team Present HHCH Patient Care Form to patients that have proven compliance issues with specific details discussed prior to patientrsquos discharge TCCrsquos are available to Care Coordination for collaboration on all patients referred to or inquiring HHCAH Collaborating and communicating with Primary Care Providers and home care staff to insure continuity of medical care through follow up appointments Preparing and maintaining accurate patient records charts and documents to support sound medical practice Notifies appropriate hospital or physician personnel when patient is having difficulty following the transitional care program helps to identify and remove barrier to goal attainment and assists with intervention as needed Consistently communicates with HHCAH management to make sure all issues and problems are seamlessly handled so that both the patient and the SNFhospitalphysician are satisfied with the results and process Participating in case conferences and or rounds at the request of hospital andor community agency staff Providing consultation to hospital staff and or skilled nursing facilities on community resources and home care issues Adheres to the practice of confidentiality HIPAA and other statefederal regulations regarding patients families staff and the Agency Schedule education to our customers using appropriate HHCAH personnelLicensure RN or LPN with an active license to practice in the State of ConnecticutEducation Bachelorrsquos Degree preferred Associates Degree Nursing license requiredExperience Minimum of year recent homecare experience preferredSkillsDesired attributes Positive outlook Effective communicator Computer literacy including Microsoft Office and Excel efficient multi tasker experience and interest in problem resolution and process improvement A creative thinker that excels in team environmentWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your momentLicensure RN or LPN with an active license to practice in the State of ConnecticutEducation Bachelorrsquos Degree preferred Associates Degree Nursing license requiredExperience Minimum of year recent homecare experience preferredSkillsDesired attributes Positive outlook Effective communicator Computer literacy including Microsoft Office and Excel efficient multi tasker experience and interest in problem resolution and process improvement A creative thinker that excels in team environmentWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your moment