Home Health Care Transition Coordinator

Compassus - Nashville, TN

Full-time - Mid Level

Nashville, TN

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 compassionate care, effective communication, and collaboration with healthcare providers to ensure patients receive the right care at the right time. The coordinator acts as a liaison between physicians, hospital case managers, and patients, ensuring continuity of care and addressing post-acute healthcare needs.

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 Ascension professionals and problem-solve with clinicians.
• Identify steps for successful family meetings and support patients/families in 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 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 strongly preferred.
• Bachelor's degree preferred.
• Two to three years of nursing experience as an RN preferred.
• 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 in palliative care and understanding of hospice philosophy.
• Strong mathematical skills for data analysis and reporting.
• Ability to effectively present information and respond to questions from various stakeholders.

Benefits

• Health insurance