Home Health Care Transition Coordinator

Compassus - Richmond, VA

Full-time - Mid Level

Richmond, VA

Nursing and Residential Care Facilities

About the position

The Home Health Care Transition Coordinator at Compassus is responsible for facilitating smooth transitions for patients from hospital to home health care services. This role emphasizes the importance of communication and collaboration with healthcare providers, patients, and families to ensure continuity of care and adherence to the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation. The coordinator acts as a trusted resource, guiding patients through the complexities of post-acute care and ensuring they receive the appropriate services at the right time.

Responsibilities

• Meet regularly with physicians in the hospital to discuss specific patients and ensure continuity of care.
• Support transition to home health, home infusion, and hospice services by conducting in-person bedside transitions.
• Educate patient families and referral sources on hospice, home infusion, and home health benefits.
• Develop collegial relationships with other healthcare professionals to problem solve and review cases.
• Facilitate successful family meetings and support patients/families with difficult discussions.
• Maintain a current list of admission coordinators for each healthcare service line.
• Align recommendations between patient/family and primary care team, identifying patient preferences and needs.
• Facilitate 'transition to home' planning, assessing post-discharge needs and developing a transition plan.
• Set patient-centered goals and facilitate transitions, coordinating care with Home Health and Home Infusion teams.
• Conduct follow-up on re-hospitalized home health patients and participate in re-hospitalization mitigation strategies.
• Ensure excellent customer service to maintain and grow business in key accounts.
• Meet or exceed assigned quotas to improve the competitive position of home health services.

Requirements

• Active and unencumbered Registered Nurse license in the state(s) of employment.
• Bachelor's degree preferred.
• Two (2) to three (3) years of nursing experience as an RN required.
• Hospital and/or long-term care clinical experience highly preferred.
• Experience with home health eligibility admission requirements and COPs.
• Knowledge of PDGM, risk scoring/data analysis, and end-of-life practices preferred.

Nice-to-haves

• Experience with palliative care and estimating disease trajectory.
• Familiarity with homebound status determination and General Dx and LCDs.

Benefits

• Health insurance