Mount Vernon, OR
Reference Code: NEC0129
Transitional Care/Discharge Planner
JOB SUMMARY: The TRANSITIONAL CARE COORDINATOR (TCC), along with the Medical Director, provides Transitional Care Program leadership including implementation, care coordination, marketing and quality assessment. The TCC is knowledgeable of program components, ensures staff are fully trained, provides program and clinical leadership, oversees and coordinates patient-care from pre-admission through discharge, and is actively involved in all program and quality measures.
The DISCHARGE PLANNER will plan, organize and evaluate the discharge planning function of the hospital Works with members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient. The Discharge Planner maintains performance improvement activities for the Transitional Care Unit and discharge planning and reports activities to the performance improvement committee of the hospital.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
Knowledgeable of the Transitional Care Program process and clinical and CMS guidelines.
Monitors the program quality measures and supports the development of action plans as needed to improve program processes and outcomes.
Participates in marketing and referral development activities.
Identifies and develops new product lines to meet the needs of the community served.
Develops strong relationships with the other acute care hospital discharge planning staff within the referral area.
Is recognized by the care team, administration and patients and families as essential leaders.
Ensures the clinical staff complete education and training and are competent in program clinical skills.
Assess appropriateness of all referrals, engages and educates patient and family on expected discharge plan.
Ensures the Transitional Care program components are in place and functioning properly.
Ensures the collection pertinent quality metrics into the quality reporting portal.
Communicates with family member and caretakers regarding the needs of the patient and anticipated plans including community resources.
Discharge planning goals are established in coordination with the patient and family/caretaker
Maintains current knowledge of resources available within the community, maintains supply of resource materials to be distributed to patients when needed.
Follows through on all patient referrals to agencies or other medical facilities.
Accurately determines type of assistance/setting/resources necessary for the patient/family and provides appropriate resources/assistance/list of facilities.
Establish & maintain solid work relationships through communication, cooperation, and positive interaction with all employees, staff, patients and physicians.
SUPERVISORY RESPONSIBILITIES: None
Registered Nurse (RN), MSW or LCSW
1-3 years of Medical Surgical Experience in a hospital
BSN preferred and attained prior to 2020
Management experience preferred
Required: RN License, in good standing with State of Oregon
Preferred: BLS Certification Transitional Care/Discharge Coordinator
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