What are the responsibilities and job description for the Fast Track Home Hospital Care Manager position at Council on Aging of Southwestern Ohio?
Council on Aging of Southwestern Ohio (COA) is a nonprofit organization dedicated to enhancing quality of life for older adults, people with disabilities, their families and caregivers. We promote choice, independence, dignity and well-being through a range of services that help people remain in their homes for as long as possible.
COA is a state-designated Area Agency on Aging, serving a 5-county region. One call to COA links people to the wide variety of agencies, information and programs that serve older adults and people with disabilities.
COA has more than 400 employees, close to 300 contracted providers, and an annual budget of over $128.4 million.
Our mission: Enhance lives by assisting people to remain independent through a range of quality services.
Position Description (Full job description available upon request):
Improve continuity of care and improve health outcomes through consumer empowerment and enrollment of eligible patients into Fast Track Home (FTH) services, while collaborating with healthcare facilities and internal staff.
Essential Job Functions:
- Develop relationships with health care facility discharge planners, Physicians, Nursing Facilities Nurses and Social Workers.
- Proactively identifies potential clients for the Fast Track Home program.
- Assesses for program eligibility for Fast Track Home. Enrolls eligible clients prior to discharge.
- Successfully completes any necessary training and/or courses related to the evidence-based Coleman Care Transitions model.
- Utilizes evidence-based Coleman care transition model at the health care facility including:
- Coaches the client in becoming knowledgeable of all of their medications and ensures that a medication management system is in place.
- Coaches the client to understand and utilize the Personal Health Record (PHR) in order to facilitate communication and ensure continuity of the care plan across providers and settings.
- Encourages client to take a more active role in their care.
- Provides information and guidance to clients and their families.
- Coaches the client how to schedule and complete follow up visits with PCP or specialist and how to be prepared to be an active participant in these interventions.
- Coaches the client about identifying indicators (red flags) that signify his or her condition is worsening and provides client with knowledge of how to respond.
- Coaches the client in knowing where to locate information about his/her in-home services such as therapy, skilled nursing and/or HHA.
- Completes required documents and reports per program expectations.
- Educates client on cost share process should they wish to transition to ESP at the end of the FTH intervention.
Qualification Requirements:
- Associate’s degree in related field or four years of related experience or Community Health Certification or LPN required. Bachelor’s degree in Nursing, Social Work, Gerontology, Psychology, Business, Marketing, Public Administration or RN or LSW preferred.
- At least one year of experience in home health care, medical social work, geriatrics, care/case management or an equivalent substitute
- Excellent interpersonal communication skills, sales and customer service skills
- Ability to problem solve and work independently with good organization skills and the ability to manage multiple tasks
- Strong clinical skills including an understanding of and ability to implement evidence-based care
- Understanding of the health care system and its components including sites of care, delivery models, and the roles of various providers and health care professionals
- Comfort with working independently in a health care facility environment in an independent role
- Ability to think broadly and longitudinally, constantly assessing and anticipating the needs of the client and his/her environment
- Computer skills including Windows operating system; MS Word; data entry and ability to learn software applications
- A valid driver’s license and reliable transportation for travel within the COA 5-county area.
- Ability to travel within the state of Ohio for training.
- Preferred: Understanding of the health care system and its components including sites of care, delivery models, and the roles of various providers and health care professionals
Salary : $128
