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Adoration Home Health and Hospice
The Care Transition Coordinator (CTC) is responsible for facilitating a seamless transition for patients discharging from a facility setting to the care of one of our hospice agencies. The CTC verifies hospice orders, assesses patient needs, and ensures continuity of care and the agency's ability to meet the needs of the patient as they transition. Provides oversight for patients that require general inpatient care in the assigned facility and collaborate with the staff with support and education for the provision of hospice services. |
| • | Execute a weekly, monthly, and quarterly strategy to increase market share through key account development including prospecting diversification and call frequency routing. Plan activity to maximize territory coverage of both existing and prospective accounts. | |
| • | Achieve admission goals and expectations as established at hire or at review of annual agency budget goals. | |
| • | Assist the agency with preparation for accepting care of the patient post discharge from hospital. | |
| • | Coordinate other services for the patient with ancillary service providers (DME/Infusion). | |
| • | Coordinate the collection, organizing, and transfer of pertinent information for the agency staff. | |
| • | Ensure the attending physician is available to follow the patients care in the home or the transfer of primary care to the hospice medical director. | |
| • | Assist the Administrator with contract execution for facility based services for hospice patients. | |
| • | Explain hospice services and agency procedures to the patient and his/her family members. | |
| • | Involve the family/caregivers in the educational process and assess post-discharge education/coaching needs. | |
| • | Follow state specific admission criteria and timelines for admission. | |
| • | Monitor status of all patients receiving respite or general inpatient care and facilitate communication between agency, hospital, and physician. | |
| • | Participate in bi-weekly IDG meeting and if appropriate, give an update regarding accounts, customer needs, and progress toward agency growth strategies. Meet weekly one-on-one with the Administrator. | |
| • | Responsible for initial medication reconciliation with appropriate hand off and communication to visiting staff. | |
| • | Schedule follow-up call to FCC in the system 48 hours post admit. | |
| • | Serve as liaison between agency, facility care setting and referring physician. | |
| • | Provide education information for hospital staff and physicians regarding the hospice benefit and related regulations, including consulting with hospital staff or physicians regarding individual patients suitability for hospice benefits provided there is not a contact with the patient or the patients family members prior to the referral to hospice. | |
| • | Visit and communicate with the patient in the hospital to obtain necessary information to facilitate transfer. |
| • | One year hospice experience or one year hospital case management experience. | |||||
| • | Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) or Social Worker (SW) licensure in state of practice. | |||||
| • | Thorough understanding of hospice qualifying criteria and coverage guidelines.
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