LHC Group Care Transition Coordinator in New Braunfels, Texas
LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home. Hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home. More hospitals, physicians and families choose LHC Group, because we are united by a single, shared purpose: It's all about helping people.
Following Right of Choice, evaluates patient and orders for appropriateness for home care
Initiates face-to-face patient transition to identify homecare needs, and educate the patient on LHC agency and also verify patient meets Homebound criteria
Verifies patient demographic information is correct
Presents agency Executive Director with clinical assessment and identification of patient needs to obtain branch approval and acceptance
On acceptance, CTC will coordinate organization of transfer orders, educate patient on home care orders and home care services
CTC will initiate and complete CTC encounter documentation in Home Care Home Base after branch acceptance to ensure all patient needs are documented and met by the agency
Involves the family|caregivers in the educational process, assesses post-discharge educational|coaching needs, and introduces patient|family to Homecare journal for LHC Group
Identifies primary care physician to follow the plan of care
Educates patient on importance the post facility discharge follow up appointment with the physician
Assess patient’s risk for readmission using LACE tool and documents in CTC encounter
Educates patient on Homebound criteria and verifies patient meets these requirement
Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information
Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient’s understanding of medication, pharmacy, and delivery method
Coordinates other ancillary services for the patient (DME|Infusion) as needed
Assists the LHC Group agency in preparation of accepting care of the patient post discharge
Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency.
Communicates to discharge planning any active patients that transfer from home health into a Facility and coordinates resumption of care with patient prior to discharge if applicable orders are obtained
Provides follow up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency
Serves on facility committees, if requested, and works with hospital focus groups to assist in systems integration and process improvements which result in improved patient outcomes and transitions of care as approved by CTC Director
Participates in monthly Executive Director and Account Executive meetings to assist with clinical program needs
Attends all CTC Department calls and company provided in-services
Observes patient confidentiality at all times
Provides education in-services to effectively communicate the features, benefits, and specialty programs of LHC Group and to educate referral sources as to what services are available in the home
Demonstrates a desire to promote the LHC philosophy, "It’s All about Helping People" and seeks ways to facilitate helping more patients
Communicates with growth team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service areas.
Meets personal performance goals established by manager
CTC will document Start of Care transition CTC encounter note within 24hrs of patient referral/ agency acceptance and update as status of patient transfer changes
CTC will document Resumption of Care note if applicable
CMCN to be obtained within first year of employment
All other duties as assigned
- Must have one year home health experience or one year of hospital case management experience.
Must have current RN or LPN or SW licensure in state of practice
Reliable means of transportation and must have current driver's license and auto insurance
Must have excellent verbal and written communication skills with all members of the healthcare team
Must have excellent organizational skills and ability to complete competing priorities
Must have thorough understanding of home health qualifying criteria and coverage guidelines
Proficient computer skills.
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Location : Facility Name CHRISTUS HomeCare
Requisition ID 2019-69704
Location : Postal Code 78130-6114
Position Type Full-Time
Work Schedule Normal (Based on FT, PT, PRN)
Location : City New Braunfels
Location : State/Province TX
An equal opportunity employer
LHC Group is an equal opportunity employer. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status or any other legally protected status. To learn more about the opportunities for you with LHC Group and our affiliates, contact one of our Human Resources team members at 1.866.LHC.Group.
Found here: http://lhcgroup.com/careers