Berkshire Health Systems - Pittsfield, MA
posted 3 days ago
About the position
The Home Care Transitions Coordinator (HCTC) is a clinical position within Berkshire Visiting Nurse Association (BVNA) designed to enhance communication among health care providers to ensure continuity of care for patients transitioning from Berkshire Medical Center or LTC facilities to the home health care setting. HCTC also facilitates acceptance of this transition by implementing various functions. The coordinator serves as a consultant to other professionals, including hospital staff and physicians, by providing clinical expertise in the area of home healthcare. They prioritize referral information in a timely manner, supporting agency productivity related to admissions and resumption of care visits. The HCTC coordinates initiatives to reduce BVNA Acute Care Hospitalization Rate and engages in in-person, onsite visits with patients to assess clinical needs, gather clinical information, and review current physician orders. They facilitate patient participation in their own care and confirm caregiver support when applicable. Additionally, the HCTC provides education related to home health benefits and responsibilities, obtains information required for successful transition to home, collaborates with Case Management and BVNA Intake Department to promote safe discharge planning, and educates all collaborative partners regarding home health regulations and agency changes. They also coordinate with BVNA Utilization Review to ensure consistency of diagnosis accuracy with clinical referral data.
Responsibilities
- Serve as a consultant to other professionals including hospital staff and physicians by providing clinical expertise in home healthcare.
- Prioritize referral information in a timely manner to support agency productivity related to admissions and resumption of care visits.
- Coordinate initiatives to reduce BVNA Acute Care Hospitalization Rate.
- Engage in in-person, onsite visits with patients to assess clinical needs and gather clinical information.
- Facilitate patient participation in their own care and confirm caregiver support when applicable.
- Provide education related to home health benefits and responsibilities as well as regarding BVNA.
- Obtain information required for successful transition to home.
- Collaborate with Case Management and BVNA Intake Department to promote safe discharge planning.
- Educate collaborative partners regarding home health regulations and agency changes.
- Coordinate with BVNA Utilization Review to ensure consistency of diagnosis accuracy with clinical referral data.
Requirements
- 2-3 years of home health experience preferred.
- Knowledge of certified home health agency regulations related to Intake.
- Excellent time management skills.
- Good verbal and written communication skills.
- Ability to carry out detailed written or verbal instructions independently.
- Ability to coordinate the delivery of nursing care for several patients at a time.
- Experience working with physicians and paraprofessionals to prioritize patient care needs.
- Service rendered to patients to include adolescents, adults, and geriatrics.
Nice-to-haves
- BSN preferred.
