Transitional Care Coordinator - Home Health & Hospice

About Us :

At Interim Healthcare, we believe Hospice & Home Health care is more than a serviceits

a calling. Every day, our team brings comfort, dignity, and peace of mind to patients and

families facing lifes most delicate moments. With compassion at our core, we create a

workplace where kindness leads, voices are heard, and every role carries purpose. If youre

looking to make a difference in the lives of others while being part of a team that feels like

family, wed love to welcome you.

Job Summary :

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The Transitional Care Coordinator is responsible for

managing the transition of patients from hospital care to home health care

services. This role involves coordinating with hospital staff, home health care

teams, patients, and their families to ensure continuity of care, compliance

with care plans, and effective communication across all parties.

Essential Functions :

Conduct

comprehensive assessments of patients transitioning from hospital to home

health care.

Develop

and implement individualized care plans in collaboration with healthcare

providers, patients, and their families.

Evaluate

the patient's home environment to ensure it is suitable for their care

needs.

Serve

as the primary liaison between hospital staff, home health care teams,

patients, and their families.

Ensure

timely and accurate transfer of medical information and care plans.

Facilitate

communication between all parties involved in the patients care

Coordinate

the discharge process from the hospital, ensuring all necessary medical

equipment, medications, and supplies are arranged.

Schedule

follow-up appointments and coordinate transportation if needed.

Monitor

patients progress and address any issues that arise during the transition

period.

Educate

patients and their families about the home health care process, care

plans, and self-care techniques.

Provide

ongoing support and resources to patients and families to help them manage

their health conditions at home.

Maintain

accurate and up-to-date patient records in accordance with healthcare

regulations and organizational policies.

Ensure

compliance with all relevant health care standards and protocols.

Monitor

and report on patient outcomes and the effectiveness of transitional care

plans.

Work

closely with multidisciplinary teams including physicians, nurses, social

workers, and therapists to coordinate comprehensive care.

Participate

in regular team meetings and case conferences to discuss patient care

plans and progress.

Additional Responsibilities :

Performs

other duties as assigned or requested.

Conforms

to all applicable Agency policies and procedures.

Participates

actively in continuing education and in-services.

Maintains

confidentiality of patient information and business trade practices

Assumes

accountability for reporting incidents and complaints according to Agency policy.

Knowledge / Skills / Abilities :

Organizational

skills

Ability

to supervise in accordance with Agencys policies and applicable laws.

Strong clinical assessment and care

planning skills

Ability to work independently and as

part of a team

Ability to respond to common inquiries

or complaints, regulatory agencies, or members of the business

community.

Time

management

Cooperative

attitude

Advanced

written and verbal interpersonal communication

Basic

math skills related to patient care.

Age-Related Competencies :

Demonstrates

the basic knowledge and skills necessary to identify age-specific patient needs

appropriate for

this

position.

Information Management :

Treats

all information and data within the scope of the position with appropriate

confidentiality and security.

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tasks may involve exposure to bloodborne pathogens; moderate stress and

emotional demands.

Physical Requirements : Sitting is required.

Requires ability to always handle stressful situations in a calm and courteous

manner. Requires working under some stressful conditions to meet deadlines and