Care Transition Coach (LPN) - North Fulton Medical Center

Wellstar Health System • Full-time • Roswell, Georgia, United States • 3w ago

Facility: North Fulton Hospital

Job Summary:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transition Coach is to empower the patient/care giver in the following ways:
To assert a more active role during discharge and transitions of care from one setting to another.
To develop lasting self-management skills.
Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
Oversight of medication management process, including the patient's ability to pay for medications and providing adequate support with obtaining medication prior to discharge.
It is expected that all Care Transition Coach's (LPN) are licensed, knowledgeable and uphold the practice of nursing as outlined by the Georgia Professional Nurse Practice Act and implement the Nursing Practice Standards and Code for the Licensed Practical/Vocational Nurses put forth by the National Federation of Licensed Practical Nurses, Inc. (NFLPN). As a member of the patient services team, it is expected that the individual upholds the voice of the patient, system policies and procedures, while supporting service excellence goals.

Core Responsibilities and Essential Functions:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
- To assert a more active role during discharge and transitions of care from one setting to another.
- To develop lasting self-management skills.
- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
- To assert a more active role during discharge and transitions of care from one setting to another.
- To develop lasting self-management skills.
- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
- To assert a more active role during discharge and transitions of care from one setting to another.
- To develop lasting self-management skills.
- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge.

Required Minimum Education:

Diploma (Nurse) Nursing Practice

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

Lic Practical Nurse
Basic Life Support or BLS - Instructor

Additional License(s) and Certification(s):

Required Minimum Experience:

Previous experience with patient coaching Required

Required Minimum Skills:

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