Transitions of care from hospital to post-acute settings (including home) are high risk times for patients that often result in adverse events and readmissions. The Alameda Alliance for Health has launched a new multidisciplinary Transitions of Care team focused on providing support, care coordination, and coaching/education for patients at increased risk of readmission. The Transition of Care (TOC) Health Navigator works under the direct supervision of the Manager, Transition of Care and is part of a team of TOC Nurses, TOC Social Workers, and TOC Pharmacists. The TOC team is responsible for coordinating the care transition and follow-up from the acute hospital to home or facility for the initial 30 days post hospital discharge. While the TOC Health Navigator participates in all aspects of the transition of care process, the Health Navigator’s fundamental role is to support clinical staff through the completion of components of the Transition of Care program. This role will focus on members at high and moderate risk of readmissions and other post-discharge adverse events.
Principal responsibilities include:
· Assist clinical staff in identifying and providing outreach, orientation, and comprehensive assessment services to moderate and high risk members that may benefit from transitions of care support.
· Engage members while they are still in the hospital, by phone or face-to-face, introducing them to the program.
· Empower members to take an active role in their discharge planning and post-acute care by providing education, tools and support to foster self-management and to successfully respond to common problems that arise during transitions.
· Use patient goals and values to help develop care plan. Discuss advanced care planning and advanced directives when appropriate.
· Collaborate with the hospital providers and, case managers, PCPs, and other members of the care team to create and implement transition of care plans.
· Consult with Medical Director, Concurrent Review team, and other AAH internal stakeholders to anticipate and coordinate discharge needs and prevent readmissions and/or inappropriate ED use
· Participate in evaluation of Transitions of Care work-flows and processes as part of continuous quality improvement work
· Coordinate with family and caregivers as appropriate
· Utilize guiding principles and practice strategies of Motivational Interviewing with patient and family caregivers
· Provide telephonic or in-person counseling, teaching, and care coordination
· Utilize patient coaching techniques to build confidence and competence in the transitions of care plan as it relates to: medication management, follow-up appointments, knowledge of red flags related to their condition and how to Schedule primary care follow up within 3-5 business days after hospital discharge; ensure Care Transition plan is provided to PCP including the patient’s most important health concerns and the patient’s immediate goals for recovery.
· Assist patient with transportation to post-discharge follow up appointments
· Establish and leverage relationships with hospital discharge planners, inpatient social workers, primary care practices, and community and social service agencies to ensure the needs of members are met and policies of the plan are followed
· Responsible for completing and maintaining all documentation by the appropriate time frame
· Participate in weekly TOC team meetings and other UM and/or CMDM meetings as necessary
· Participate in case conferences as needed
· Meet case load assignments and productivity metrics as set my management
· Track appropriate metrics and reports back to team on weekly basis about barriers, challenges, achievement, key learnings
· Maintain professional and technical knowledge
· Perform other duties as assigned
ESSENTIAL FUNCTIONS OF THE JOB
· Assist clinical staff in communicating and coordinating with PCPs , specialists, hospitals, and other providers on behalf of members
· Communicate with members and providers to ensure coordination of services for members
· Build and maintain effective relationships with members and designated families or caregivers
· Communicate effectively and efficiently internally and externally
· Develop relationships with appropriate community resources to help support members
· Provide direction to staff members who will provide additional coordination activities for health plan members
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Assist case managers in communicating and coordinating with PCPs, specialists, hospitals, and other providers on behalf of members.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and mouse.
· Constant use of a telephone head-set.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Bachelor's degree or higher in health care related area of study.
· AS/AA degree or two years of college with a minimum of one year experience making healthcare related assessments and referrals, and/or experience in working with diverse clients with multiple barriers including physical and behavioral health.
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum two year experience in the healthcare, public health, or social services sectors, preferably in a health plan setting
· Working knowledge of medical and insurance terminology, including knowledge of acute and chronic medical and behavioral health related topics.
· Minimum one year experience in working directly with clients/patients in an outpatient clinic, managed care, home care or inpatient setting
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Proficiency in correct English usage, grammar, and punctuation.
· Fluency in English required.
· Fluency in Vietnamese, Cantonese, or Spanish, preferred
· Experience in managed care organization or health plan preferred
· Experience working in the safety net setting or with underserved populations preferred. If none, sensitivity to challenges of a diverse, low income community.
· Experience working with case managers (nurses and/or social workers) preferred
· Experience interacting with physicians, physician offices, hospital discharge coordinators and/or community-based programs preferred.
· Ability to multi-task and prioritize multiple projects and daily work requirements
· Working knowledge of managed care preferred.
· Working knowledge of RVS, CPT, ICD-9, ICD-10, and CPT 4 preferred.
· Communicate effectively, both verbally and in writing.
· Strong organizational skills, proactive and detail-oriented.
· Excellent active listening, interpersonal, verbal and written communication skills; ability to communicate with empathy.
· Ability to work in a team environment, as well as independently.
· Ability to act as resource.
· Familiarity with Alameda County resources a plus.
· Ability to work within guidelines and protocols to achieve decisions independently.
· Possess and maintain a valid California driver’s license and auto liability insurance.
· Proficient experience in Windows including Microsoft Office suite.