Summary The Transitional Case Managers(TCM) primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post-acute care needs. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The TCM will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs the TCM will begin best practice intervention and education to improve patient outcomes and promote patient self-management. The TCM will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home. Shift will be weekends, PRN. Responsibilities Identifies primary care physician to follow the plan of care Educates patient on importance of the post facility discharge follow up appointment with the physician Assess patient’s risk for readmission using LACE tool and documents in Transition encounter Educates patient on homebound criteria and verifies patient meets these requirements Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient’s understanding of medication, pharmacy, and delivery method Coordinates other ancillary services for the patient (DME|Infusion) as needed Assists the LHC Group agency in preparation of accepting care of the patient post discharge Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency Communicates to discharge planning any active patients that transfer from home health into a Facility and coordinates resumption of care with patient prior to discharge if applicable orders are obtained Provides follow up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency Serves on facility committees, if requested, and works with hospital focus groups to assist in systems integration and process improvements which result in improved patient outcomes and transitions of care as approved by Director Participates in monthly Executive Director and Account Executive meetings to assist with clinical program needs Attends all Department calls and company provided in-services Observes patient confidentiality at all times Provides education in-services to effectively communicate the features, benefits, and specialty programs of LHC Group and to educate referral sources as to what services are available in the home Demonstrates a desire to promote the LHC philosophy, "It’s All about Helping People" and seeks ways to facilitate helping more patients Communicates with growth team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service areas Meets personal performance goals established by manager Documents Start of Care transition CTC encounter note within 24hrs of patient referral/ agency acceptance and update as status of patient transfer changes Documenst Resumption of Care note if applicable CMCN to be obtained within first year of employment All other duties as assigned Education and Experience Experience Requirements Must have one year home health experience or one year of hospital case management experience. License Requirements Must have current RN or LPN or SW licensure in state of practice Reliable means of transportation and must have current driver's license and auto insurance Skill Requirements Must have excellent verbal and written communication skills with all members of the healthcare team Must have excellent organizational skills and ability to complete competing priorities Must have thorough understanding of home health qualifying criteria and coverage guidelines Proficient computer skills.