Resident Care Coordinator

RN Preferred

The mission of the Resident Care Coordinator is to provide person centered coordination of care to short stay residents. This person will insure that that the patient and family goals are met to achieve the best possible outcomes to allow the resident to return to the highest level of independence possible. This person will work independently and within the interdisciplinary team to provide support, education, coaching, care management and care coordination of the resident as it relates to the transition of care from hospital to center, transition of level of care within the center and the transition back into the community-based setting. Resident experience from pre-admission to discharge will be central to the success of the position.

Responsibilities and Duties:

Transition to the Center: Pre-admission

· Receive referral inquiry from providers, facilities, or any customer source and provide on-site assessment service to referring providers.

· Meet with residents and families in the hospital, as allowed, to discuss the transfer process, anticipated admission experience, expected outcome and financial implications.

· Determine the special needs of that resident (i.e. equipment, staff) and assist facility staff to obtain appropriate devices and equipment.

· Communicate transfer, admission, clinical and financial information to appropriate facility staff members. Ensure that the facility is prepared for admission.

· Obtain the necessary medical and financial information to complete the initial admission process, obtaining back-up documentation from the hospital as support.

· Coordinate resident placement based on clinical services needed, bed availability, resident/family preference, geographic location, etc.

· Manage relationships with referral sources and provide information regarding current services. Assist facility to respond promptly and to meet their placement needs. Additionally, regular visits should serve as an educational service in which the hospital learns of the facility’s new, enhanced or existing services and capabilities.

· Coordinate facility tours and admission conferences for referral sources, potential residents and their families.

Transition to the Center: Admission

· Perform initial assessment with 24 hours of admission. Assessment will include but not limited to ascertaining patient and family goals of the stay at the center, patient understanding of the transition of care to the center, prior level of functioning, prior services in place within the community, patient understanding of present diagnosis(es), medications and conditions, prior services in place prior to hospitalization, ascertain prior medication list.

· Ascertain primary care physician, specialists and provide follow up notification that patient is at our center

· Provides general center orientation and expectations of level of care of a skilled nursing facility

· Coordinate the initiation of a short-term plan of care / baseline care plan.

Transitions of Level of Care Required in Center: During stay

· Attends Utilization Review Meetings and updates short stay plan of care and responsible to communicate that to patient and family.

· Collaborates with MDS department to assure accurate assessment.

· Next day follow-up and intermittent communication with family and /or resident to obtain feedback and enhance the resident experience. Communicate such feedback to IDT to confirm feedback communicated and actioned.

· Collaborates with social workers to obtain financial, Home and Community Based Services and social services.

· If a patient is transitioned back to hospital, the coordinator is responsible to follow up with families to assist and guide them to make decisions based on the goals set upon admit to center.

Transition to Community: Discharge

· Collaborates with IDT to ensure home going plans are initiated and feedback received on resident experience.

· Share client experience feedback with IDT and address concerns, request testimonials and reviews.

· Provide education to staff based on changes implemented due to resident feedback.

Job Qualifications:

Registered Nurse preferred

3-5 years nursing experience, case management a plus

Understanding of post acute care

Understanding of Chronic disease management specific to geriatrics

Experience working on an IDT team

Established HCBS relationships

Qualities:

Passionate for Resident Centered Care

engaging and energetic

team player

excellent listening skills: need to be proficient in open ended questioning , investigative

self starter

awareness of self and others

excellent communicator

compassionate and patient

computer literate

strong clinical knowledge

desire for patient and family advocacy

educating and coaching

adaptable and flexible in approach

creative problem solving skills