Transition of Care Coordinator, LVN (Home Care)

The Transition of Care (TOC) Coordinator at High Desert PACE is a pivotal clinical role dedicated to bridging the gap between acute care settings and the home environment. As an LVN in this role, you will facilitate the seamless, safe, and coordinated movement of PACE participants across the continuum of care including hospitals, skilled nursing facilities (SNF), PACE centers, and private residences.

Your mission is to ensure that no participant "falls through the cracks" during a transition. By providing rigorous clinical oversight, medication reconciliation, and caregiver education, you will promote participant independence, reduce avoidable readmissions, and uphold the integrated care model that defines High Desert PACE.

Clinical Coordination & Liaison Oversight

• Active Discharge Planning: Serve as the primary point of contact between hospital/SNF discharge planners and the PACE Interdisciplinary Team (IDT). Attend discharge planning meetings to ensure the home environment is prepared for the participant’s return.
• On-Site Assessment: Visit participants in acute or post-acute facilities to assess clinical status and begin the transition planning process before they leave the facility.
• Liaison Duties: Build and maintain strong professional relationships with local High Desert hospitals and rehab centers to ensure timely notification of participant admissions and discharges.
• To ensure 24/7 participant care and safety, this position is required to participate in a rotating evening, weekend, and holiday On-Call (Call Back) program.

Post-Discharge Continuity of Care

• Medication Reconciliation: Perform comprehensive medication reconciliation post-discharge, identifying discrepancies between hospital orders and the current PACE care plan to prevent adverse drug events.
• Conduct telephonic or in-person follow-up assessments within 48 hours of discharge to monitor stability, symptom management, and adherence to the updated care plan.
• Appointment Management: Schedule and ensure transportation for all necessary follow-up appointments with PACE primary care providers or specialty consultants.

Education & Empowerment

• Health Coaching: Educate participants and their families on red flag symptoms related to their specific diagnoses (e.g., CHF, COPD, Diabetes) and provide clear instructions on who to call if symptoms escalate.
• Self-Management Support: Train caregivers on new equipment, wound care basics, or medication administration techniques required post-discharge.
• Documentation & Quality Improvement
• IDT Integration: Actively participate in daily IDT meetings, providing real-time updates on hospitalized participants and proposing modifications to the Life Plan based on transitional needs.
• Metrics & Reporting: Accurately track and report on transition metrics, including 30-day readmission rates and Time to First Follow-up to support PACE quality improvement initiatives.
• Regulatory Compliance: Maintain meticulous electronic health record (EHR) documentation in accordance with CMS and DHCS standards for PACE organizations.

Qualifications

• Licensure: Current, valid California Licensed Vocational Nurse (LVN) license.
• Education: Associate degree in nursing or a related clinical field.
• Experience: Minimum of 3+ years of experience in care coordination, transitional care, case management, or home health. Specific experience with the geriatric population and/or dual-eligible (Medicare/Medi-Cal) populations is highly preferred.
• Clinical Skills: Strong proficiency in medication reconciliation and chronic disease management.
• Soft Skills: Exceptional interpersonal communication, the ability to remain calm under pressure, and a high degree of organizational autonomy.
• Requirements: Valid CA Driver’s License and reliable transportation (for home visits and facility rounding).

Working Conditions & Impact

• Environment: This is an on-site role requiring presence at the PACE Center, potential visits to local hospitals/SNFs, and occasional home visits within the High Desert service area.
• Impact: By ensuring high-quality transitions, you directly impact the quality of life for our seniors, significantly reduce the trauma of hospital readmissions, and help maintain the integrity of our aging in place philosophy.