Job Details

POSITION DESCRIPTION:

The Post-Acute Transitional Care Manager is an integral member of the ambulatory care team.  This position is responsible for complex care management for patients in hospitals and post-acute care settings including, but not limited to, skilled nursing facilities, long-term care hospitals, inpatient rehabilitation facilities, home health agencies and patients’ homes in multiple counties in Southeast Michigan. Specific focus on patients requiring care in a Skilled Nursing Facility (SNF) is noted, as well as the dedication to providing in-person, on-site evaluation and care management. Duties will include transitional care assistance, coordination of continuing care, education and advocacy for patients in the post-acute care setting and transition back to their home.  The Post-Acute Transitional Care manager will provide communication and collaborate with the patient’s primary care office and specialists, as appropriate.

ESSENTIAL JOB FUNCTIONS:

1. Coordinates the care delivered and assists as needed with individualized patient interventions to minimize avoidable rehospitalizations for patients (and family) transitions, being admitted, discharged and transferred across the care continuum.
2. Develops a cohesive and strong team-oriented relationship with physicians, nurses and other healthcare professionals within the post-acute care setting to ensure the delivery of quality, efficient, patient centered and cost-effective healthcare services.
3. Obtains a thorough assessment of the patient which includes medical history, current clinical status, family and caregiver support and social determinants of health.
4. Assesses the family's knowledge base, expectations and the ability for a family member to act as the primary caregiver, if appropriate.
5. Assists the individual, the family and team, in identifying the variables that may influence the accomplishment of goals.
6. Establishes realistic and patient-centered short-term and long-term goals with the individual and family, reassessing progress and revisions periodically.
7. Responsible for establishing the patient care plan in collaboration with the patient and interdisciplinary care team which includes the treatment plan, disposition, progress, anticipated needs and expected length of stay. 
8. Promotes effective communication among the healthcare team members, including the patient, family, interdisciplinary team, case managers and primary care physician.
9. Advocates for the most appropriate, cost effective, evidence-based services to assure quality of care and attainment of appropriate goals. Recommends and coordinates home assessment services before discharge when appropriate.
10. Intervenes promptly when necessary to promote optimal functioning and prevention of complications.
11. Coordinates appropriate resources and supportive services to meet the patients’ needs at the time of transition to next level of care, based on collaboration with the healthcare team recommendations.
12. Provides verbal and written education to the individual and family regarding diagnosis, symptom management, community resources and supportive services.
13. Other duties as assigned.