Transitions Health Coach (Closes 6/16/2025)

Summary

The Transitions Health Coach provides thirty-day interventions to targeted patients who are recently hospitalized.  The primary role is to identify eligible clients, provide specialized intervention with the goal of preventing avoidable hospitalizations and to empower patients to be the leaders in their healthcare.  To accomplish this, incumbent will function as an information and referral source, provide a thirty-day intervention to patients and work with hospitals and health plans to prevent readmissions. The Health Coach works as a member of the multidisciplinary health care team to assure that discharge planning critical paths are followed, providing for successful care transitions.

Essential Duties and Responsibilities

§ Interacts with designated AAA staff, hospital staff and participants when active patients are admitted into the hospital.

§ Consults with hospital discharge planner, physicians and multidisciplinary teams to identify patients who would benefit from the Program.

§ Conducts assessments of need for community-based service and support and provides referrals.

§ Actively consults and collaborates with hospital multidisciplinary team in planning and executing patient transitions.

§ Actively engages patients and caregivers in the discharge planning process using valid and reliable instruments; including a discharge preparation checklist, personal health record, medication reconciliation process and plan for medical follow-up.

§ Directs engagement with patients and caregivers to complete the discharge preparation checklist, personal health record, medication reconciliation, as well as identification of educational needs in chronic disease process and self-management skills.

§ Visits patient daily at hospital to ensure that patient and family are fully engaged and prepared for care transition process, including necessary tools and competency in self-management skills.

§ Provides additional coaching and education as necessary to assure transition is executed consistent with patient and caregiver goals.

§ Visits patient within 48 hours of transition to home or other care setting to review care transition process including adherence with discharge preparation checklist, evaluation of self-management skills, medication reconciliation, caregiver knowledge and self-management skills.  Recognizes and addresses red flags and plans for medical contact and follow-up.

§ Establishes an ongoing plan for home visits and phone contacts specific to patient’s needs.

§ Tracks program and individual performance objectives and routinely reports on progress and outcomes.

§ Actively participates in readmission reviews with hospital staff and health plans.

§ Attends staff meetings and meets with supervisor regularly.

Supervisory Responsibilities

This job has no supervisory responsibilities. 

Additional Responsibilities

From time to time the employee will be required to perform additional tasks and duties as required by the employer.            

Knowledge, Skills and Abilities

§ Ability to apply various coaching methodology to cases.

§ Strong understanding of a coaching model and the ability to train others in this discipline. 

§ Ability to interact and engage with participants/family members/caregivers/direct care workers.

§ Demonstrated organizational skills.

§ Ability to work independently with minimal supervision.

§ Proficiency in Microsoft Office products.

§ Ability to work non-traditional hours, as needed.

§ Knowledge of geriatrics, home and community-based services and social services preferred.

§ Working knowledge of chronic disease self-management.

§ Experience participating on a multi-disciplinary health care team.

§ Experience working with chronically ill patients to identify patient goals and outcomes and provide education necessary for patient self-management.

§ Strong time management skills and ability to balance multiple responsibilities.

§ Strong communication skills and ability to work collaboratively with other health care professionals to assure coordination and continuity of patient care.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions, consistent with applicable law.

Education/Experience Requirements

Bachelor’s degree, plus 6 months or more experience in transition coaching.

-OR-                                                                                     

Bachelor’s degree in human services, plus 2 years’ experience working with the geriatric population.

-OR-

Any equivalent combination of education and experience that meets the required knowledge, skills and abilities.

Certificates, Licenses, Registrations

Act 33, 34 and FBI clearances

-AND-

Screening for debarment prior to hire and monthly during employment through both the Office of Inspector General and System for Award Management databases.

-AND-

Valid driver’s license and access to a reliable vehicle.

Certificates, Licenses, Registrations

Act 33, 34 and FBI clearances

-AND-

Screening for debarment prior to hire and monthly during employment through both the Office of Inspector General and System for Award Management databases.

-AND-

Valid driver’s license and access to a reliable vehicle.

Why DHS?

·       It is innovative. Most recently, the national attention and awards we’ve gotten are for how DHS integrates data and uses them to improve the safety and well-being of children through tools that support front-line staff in making decisions (using predictive analytics).

·       DHS is diverse, but we strive to be even more inclusive. Our director has made it her top priority that DHS is “the kind of place where a diverse group of talented people want to come, grow, and do their best work.” This includes equity in hiring and advancement, as well as in unleashing the creativity and ideas of staff at every level of DHS.

·        It has strong, assertive leaders. We do not hire yes-people.

 You can make a big impact here. We stand out as one of the best human services organizations in the country. But we need problem-solvers, innovators, and terrific leaders to make sure we are smart in how we use our funding so that we reach the people who most need our help to make their lives better. 

 DHS strives to be the kind of place where a diverse mix of talented people want to come to grow and do their best work.