Transitions of Care LPN

Job Summary

Under supervision of the provider, provide comprehensive coordination of care for patients as they transition from the hospital setting into the provider office for follow up care. Work closely with the hospital transitional care teams to identify AMG patients being discharged and contact the patient to arrange timely office visits. Eliminate barriers to timely care, facilitate flow through system, facilitate interactions with the office team and providers, increase patient and provider satisfaction, maintain point of contact with providers and serve as the first point of contact for transitional care patients.

Duties And Responsibilities

• Oversees the planning, scheduling, and implementation of transitional care patients for AMG offices. Acts as a central point of contact for hospital transitional care teams. Manages the Patient Ping report to identify both local and regional discharge of AMG patients for possible Transitional Care visits.
• Collect and report data from patient on barriers, health care, medications, prior treatments, etc. and support the provider in proper transitional care visits.
• As a part of the PCMH process in AMG, track order completion and follow up. Monitor patient compliance with patient treatment plan.
• Assist with PCMH, ACO and Quality program processes at AMG.
• Assist transitional care patients with referrals to outside resources and care coordination as needed.
• As needed, Prepares patients for examination, tests, or treatments and explains procedures.
• As needed, takes patients’ histories and vital signs, and performs EKG as needed. Administers injections, medications, and treatments as required.
• Ensures electronic medical records are updated promptly and accurately.
• Triages calls and responds to phone messages, completing and committing when appropriate or forwarding to physician for proper advice. Schedules patients for appointments when necessary.
• Follows established departmental policies, procedures, and objectives, continuous quality improvement objectives and safety, environmental, and/or infection control standards.
• Collaborates with medical providers, patient care staff and clinic management in the planning and implementation of patient and staff education.
• Attends required meetings and participates in committees and professional development activities.
• Designs or participates in the creation of health education materials.
• Performs miscellaneous job-related duties as assigned
  
  

Knowledge, Abilities

• Knowledge of the principles and skills needed for practical nursing to provide patient care and treatment.
• Ability to communicate clearly with individuals of all levels and establish and maintain effective working relationships with providers, staff, patients and the public.
• Knowledge of examination, diagnostic and treatment room procedures.
• Knowledge of common safety hazards and precautions to establish a safe work environment.
  
  

Minimum Requirements

Graduation from an accredited School of Nursing.

Valid and unrestricted Connecticut State License of Practical Nursing.

One year medical office experience, including quality programs.

Environmental Working Conditions

Exposure to bodily fluids, illness and disease

Physical And Mental Demands

Requires full range of body motion, including handling and lifting patients; manual dexterity; eye-hand coordination. Involves frequent standing and walking. Requires the ability to work in a busy medical office environment.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.