The Care Transitions Associate develops strong relationship role with Hospital/Health System providers, Hospitalists, Physicians, Home Health and others as identified within assigned geographic area to align population sub-acute requirements to Genesis' strategy with the intent to grow referral volume through the delivery of market-leading patient outcomes.
The Care Transitions Associate ensures safe and effective transfers of patients across the care continuum serving as a bridge between the hospital and skilled nursing facility setting, staff and the patient and/or family with the objective to reduce rehospitalizations and improve customer satisfaction.
Expand customer base by increasing center occupancy and skilled mix from assigned hospital accounts and/or mining unassigned hospital accounts. Apply Genesis standards to make patient acceptance and placement decisions and communicate decisions to referral sources.
Balance of responsibilities and accountabilities may vary based on the strategic nature of the hospital/health system account.
Relationship Building - Communication:
1. Reposition Genesis as a strategic partner with select referring hospitals by concentrating interactions on patient cases and improved outcomes e.g. reduction in unnecessary re-hospitalizations.
2. Encourage meaningful collaboration with hospital-based case managers on risk factors and care plans, expanding concentration of marketing focus on external relationship development beyond bed availability.
3. Identify new opportunities for growth partnering, e.g. promote new service offerings e.g. Vitality To You (V2U), offer solutions for target populations, e.g. advanced payment models, etc.
4. Educate hospital staff, including Emergency Department physicians, of nursing centers' clinical capabilities and appropriate patients for return to (or, with the availability of a 3 day waiver, admission to) skilled nursing facility as an appropriate alternative to acute care transition.
5. Plan and manage business activities based on an updated quarterly business plan with quantifiable goals. Update hospital and community accounts, associated contacts and corresponding marketing action plans (MAP) as directed by Division Leadership. Maintain a set visitation schedule to assigned hospitals.
6. Collaborate with Discharge Planner and/or electronic discharge systems to identify patients for transition, prioritize referrals and activities according to intensity (level of care), urgency, risk level and required follow-up.
7. Collect pre-admission clinical and financial information to review patient needs and preferences accurately either personally or telephonically and to identify optimal service location.
8. Follow Pre-Admission Policy and Clinical Acceptance Criteria to make placements decisions and reserve bed in PCC as evidence of decision.
9. Visit patient/family bedside to collect data for contribution to the complete assessments for risk identification and care plan initiation.
10. Consult with RN regarding facts/determination of the patient case to identify and communicate risk factors and collaborate with hospital liaison to consider possible hospital stay extensions, when indicated, to reduce re-hospitalizations.
11. Leverage access to hospital-based information systems, electronic discharge systems, health information exchanges in absence of centers' access to support transitional care information.
12. In collaboration with Discharge Planner and center, schedule patient transition to center and if applicable, obtain pre-authorizations from managed care organizations for beneficiaries.
13. Communicate patient status and risks to the nursing center inter-disciplinary team and Transitional Care Nurse (SNF to Home) either electronically or telephonically.
14. Document thoroughly, completely and timely, in PCC, patient status, clinical and financial information and reservation so center can prepare to admit.
15. Upon notification of a rehospitalization event, re-engage with re-hospitalized Genesis patients to ensure patient return to Genesis facility when appropriate.
16. Arrange and lead regular meetings with appropriate hospital staff to review cases for patients with high frequency of re-hospitalizations, participate in root cause analysis and development/implement performance improvement plan.
17. Provide advice on efficacy of existing tools and make recommendations for improvement.
18. Monitor business contacts, referrals, admissions, re-admissions and dispositions and communicate changes in trends or referral patterns to appropriate staff and management.
19. Maintain, timely and accurately, Genesis electronic medical record PCC and Allscripts/Curaspan on patient population.
20. Maintain a working knowledge and adhere to applicable federal/state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA.
21. Interact in a manner which is professional, respectful, positive, customer-focused and which promotes trust.
22. Maintain professional growth and development.
Position Type: Full Time
Req ID: 325023
Center Name: Genesis HealthCare