Monday, September 23, 2013

Care Transition Coordinator

About Extendicare

Extendicare REIT, through its wholly owned subsidiaries, operates 235 long-term care facilities across North America, with capacity for over 26,800 residents. As well, through its operations in the United States, Extendicare offers medical specialty services such as subacute care and rehabilitative therapy services, while home health care services are provided in Canada. The Company employs 34,000 people in the United States and Canada.

Under the supervision of the NHA, the Care Transition Coordinator assumes responsibility and accountability for collaborating, directing, following and coordinating the l care and services provided by skilled nursing facility staff to meet the patient's needs, as well as the goals of acute and post-acute continuum of care providers. Leadership is provided to interdisciplinary team through team meetings designed to communicate each patient plan of care and goals. Care Transition Coordinators adheres to standards of care, manages the environment to maintain resident/patient safety and ensure Customer satisfaction throughout stay. Follows all Extendicare policies and procedures and performs duties as defined by his/her State Nurse Practice Act.

Essential Functions:

1. Responsibilities

- Coordinates the work of employees to meet patient goals and expectations

- Preadmission onsite visit with medical record review (where feasible), patient/responsible party and hospital caregiver interviews to facilitate coordinated care upon admission to skilled facility

- Assists with resolution to all short stay patient/family concerns. Communicates opportunities for improvement to Department Managers

- Participates in training programs and assists in orientation of all staff

- Attends stand-up meeting and reviews 24 hour report

- Daily review of planned admissions and readmissions as well as readmissions to hospital within 30 days of admission to skilled facility

- Attends daily triage and clinical meetings as well as interdisciplinary care meetings for all short stay patients

- Reviews daily documentation on assigned patients to include Physician Orders and ensures follow through consistent with patients plan of care

- Coordinates patient and responsible party education regarding disease process and management with interdisciplinary team to include medication management at time of discharge and as part of post discharge follow up.

- Communicates Recovery Track plan to assigned patient and responsible party throughout stay

- Facilitates reintegration into community with Social Services staff, patient, responsible party and post skilled facility partners to include Primary Care Physician follow up appointment, notification of discharge and summary of stay.

- Manages Extend to Home program for all discharges. Tracks and trends results and assists in resolution for individual concerns as well as identified, trended opportunities for process improvement

- Coordinates assigned patient population care with acute and other post acute providers including arrangement for Primary Care Physician follow up visit.

- Participate on project teams with acute and post acute providers to develop processes, tools and programs to reduce avoidable readmissions and improve patient outcomes

- Collects and evaluates outcome data, including re-hospitalization rates, for next step patients.

2. Complies with laws and regulations applicable to position and act in accordance with Extendicare Health Services, Inc.s Corporate Compliance Program.

3. Treats all residents, visitors, and staff with courtesy.

4. Attends and participates in in-service training, performance improvement (PI) committees and other meetings as scheduled and directed.

5. Follows facility dress and hygiene policies.

6. Safety

- Knows and follows facility rules

- Demonstrates proper use of equipment. Reports equipment in need of repair

- Follows facility smoking policy

- Reports and documents any incidents and accidents of patients, staff or visitors to the appropriate facility personnel

- Reports all hazardous conditions/equipment to Supervisor

- Performs duties, which may include transportation of patients as outlined in facility Disaster Plan

- Uses required Protective Equipment as outlined in Infection Control Program

- Follows infection control standards, policies and procedures.

7. Resident Rights

- Knows Resident Rights. Helps the residents/patients exercise and/or protect their rights.

- Reports patient complaints to management

Education: Possesses a current license to practice in the State as an RN.

Experience: At least one year of prior supervisory experience preferred. Prior experience working in a long-term care facility required.

Skills, Knowledge and Abilities: Ability to relate positively, effectively and appropriately with residents, families, community members, volunteers and other facility staff. Possess special interest in, and a positive attitude about, working with long-term care residents and the elderly. Ability to read, write, speak and understand English. Meets all health requirements, as required by law. Knowledge of long term rules and regulations. Proficient in Microsoft Office version 1997, 2000 or XP, E-mail, Outlook, Internet Explorer


If you can hear yourself saying one of the following:

"Helping People Live Better."

"Revolutionizing Post-Acute Therapy."

"IT Solved."

A challenging and exciting career at Extendicare, ProStep or VCPI awaits you. We value our customers and our teams who care for them. We are enthusiastic about helping others by providing quality care, rehabilitation and IT services. If you are interested in a rewarding career, passionate staff, and a diverse team apply today.

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