Transition Coach PT Days at AdventHealth

Date Posted: 12/30/2021


Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
    Case Management
  • Shift
    1 - Day

Job Description


Transition Coach AdventHealth Shawnee Mission

Top Reasons To Work At AdventHealth Shawnee Mission

  • Received Magnet® recognition from the American Nurses Credentialing Center in January 2019
  • Providing faith-based, whole person care to Kansas City since 1962
  • Excellent health benefits, an onsite child care center and fitness facility  
  • Tuition reimbursement to support continuing education
  • Employee Referral Program
  • Largest health care provider in Johnson County with three campuses
  • Benefits begin on Day One

Work Hours/Shift:

Part Time, Days

You Will Be Responsible For:

  • Demonstrates and conveys a favorable image of the Medical Center.
  • Attend in service programs of continuing education and review current literature as a means to evaluate and enhance current treatment practices.
  • Adjust and enhance clinical expertise to meet changing healthcare needs.
  • Admit mistakes openly and seeks ways to correct the problem.  Create a safe environment for honest and open communication.
  • Seek appropriate consultation.
  • Incorporate and maintain a professional practice pattern that includes assessment of psychosocial functioning, adaptation to illness, post hospital planning, and psychosocial assessment/evaluation and facilitates referrals to community agencies, financial planning and provision of information and resource knowledge.
  • Apply appropriate criteria to identify patients who are at high risk for readmission or for high emergency room utilization.
  • Display a high level of flexibility, adaptability and organization skills in response to the caseload and to effectively prioritize cases.
  • Conduct patient and family education, utilizing Teach Back method.
  • Identify and advocate of client needs lacking in community systems.
  • Function as a treatment team member, interpreting social, psychological, emotional and family system problems and strengths to other members of the treatment team.
  • Incorporates patient, physician, customer needs and concerns into decision-making and organizational action.
  • Form collaborative working relationships with key community agencies.  Partner with other community resources to leverage range of service provided to the client and client system.
  • Prioritize clinical problems, formulate treatment goals and construct treatment plan, revising as needed, based on continuous evaluation and assessment of progress.
  • Provide an in-depth comprehensive psychosocial assessment of the patient and their support system as needed. Identify and intervene regarding specific age and developmental issues for older adults.
  • Acquires working knowledge of motivational interviewing and working with resistant clients.
  • Document direct service in patient’s medical record after each significant contact and at closure of case, according to Shawnee Mission Health and regulatory standards.
  • Evaluate practice upon completion of case intervention, determining whether intervention was adherent to contract and whether client achieved expected outcome.
  • Demonstrates ability to quickly appraise crisis situation and select appropriate intervention(s).
  • Mediate highly complex situations and develop treatment plans with minimal supervision.
  • Participate in community outreach and marketing through: public speaking, in-services, workshops, conferences and community presentations.
  • Participate in various hospital and department committees, including Performance Improvement (PI) activities.
  • Function as a field practicum instructor for University students as appropriate.
  • Attend patient care meetings to educate interdisciplinary team how to make appropriate referrals regarding patients needing transitional coaching services.
  • Produce expected quantity of services as determined by worker time/caseload allocation plans.
  • Accept special projects as assigned.
  • Provide and record ongoing data on caseload for purposes of program evaluation.
  • Make follow up visits to the patient at location of post discharge transfer.
  • Identify gaps in service that prevent the patient from achieving increased stability in daily living.
  • Participate in ongoing program evaluation with Physician Champions.

What You Will Need:

  • Bachelor’s Degree in Nursing OR
  • Master’s Degree in Social Work
  • 1 to 2 Years of Position-Related Experience Required; 2 to 5 years preferred
  • Kansas Registered Nurse License OR
  • Kansas Licensed Master Social Worker (LMSW) OR Kansas Licensed Specialist Clinical Social Worker (LSCSW)

Job Summary:

The Transition Coach will implement the AdventHealth Readmission Prevention model targeted to reduce the number of patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. The Transition Coach will initially meet patients in the hospital and will follow selected patients who transition from the hospital to a lower level of care. Patients will be identified by various methods including the use of Cerner Quality Consoles, Care Coordination meetings and the BOOST tool. Strategies for patient management include but are not limited to Teach Back method of discharge instruction, assistance in setting up PCP appointment within 72 hours, home visits to assist with medication reconciliation and other self -management techniques, ongoing telephone follow up, assistance with psychosocial issues and gaps in service and support of caregivers as appropriate. Transition management will be provided to patients who discharge to a destination other than home and the strategies will be appropriate to that level of care.  The Transition Coach will work as part of an interdisciplinary Transitions Team including acute care case managers, social workers, home care liaisons, physicians, pharmacists, nursing leadership and staff nursing. This position will also work as part of various other teams, including the Continuing Care Team on each unit. The Transition Coach will also participate in routine readmission meetings with community partners as well as comply with data collection expectations

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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