The incumbent in this position acts as an advocate for hospitalized patients with complex respiratory conditions (ie: sleep apnea, chronic obstructive pulmonary disease (COPD), tracheostomy, etc) and is responsible for coordinating care and services not only during the inpatient stay, but also coordinating appropriate follow-up care in the outpatient setting. Promotes effective resource utilization, provides comprehensive patient education, and assumes leadership with the multidisciplinary team to achieve optimal clinical outcomes and prevent readmissions for the population.

Essential Job Functions

• Demonstrates excellence in communication skills and patient interactions. Demonstrates ability to work as a team member both intra- and interdepartmentally.
• Facilitates the coordination of patient care services to assure excellence in patient care and patient flow, including care coordination, treatment, and communication among the medical team. Develops coordinated plan for follow-up care prior to discharge including proper medication and activation devices
• Works with interdisciplinary team to ensure all diagnostic elements required for specific diagnoses are completed or scheduled for completion prior to discharge.
• Acts as a resource to providers, patients, and other members of the health care team in trouble-shooting and obtaining data, reports, supplies, equipment, etc. needed to care for the hospitalized patient with complex respiratory conditions.
• Demonstrates expertise in education and resourcing services by providing comprehensive education to hospitalized patients with complex respiratory conditions and developing new educational materials needed for patient education.
• Works with care team to ensure direct care needs are met, assisting as needed or assigned.
• Designs and implements a system to ensure gaps in transitions of care are identified and addressed as needed.
• Contributes to an environment of quality and process improvement including active participation in the COPD Readmissions work group.
• Collaborate with patient and chosen home care DME company to ensure any equipment or supply needs are addressed prior to discharge.