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Transitions Health Coach Full-time

at Great Lakes Behavioral Research Institute in (Published at 13-02-2018)

General Information Location 2100 Wharton Street

Pittsburgh, PA 15203

United States Base Pay $35,000.00-$38,000.00 / Year Job Category Professional Description
We are seeking a Transitions Health Coach to provide thirty day interventions to targeted patients who have been recently hospitalized. The main function of this role will be to identify eligible clients, provide specialized intervention with the goal of preventing avoidable hospitalizations and to empower patients to be the leaders in their healthcare. To accomplish this, the Transitions Health Coach will act as an information and referral source, provide a thirty day intervention to patients and work with hospitals and health plans to prevent readmissions. The Transitions Health Coach will also work as a member of the multidisciplinary health care team to assure that discharge planning critical paths are followed, providing for successful care transitions. Additional responsibilities will include:

  • Interacting with designated AAA staff, hospital staff and participants when active patients are admitted into the hospital.
  • Consulting with hospital discharge planner, physicians and multidisciplinary teams to identify patients who would benefit from the Program.
  • Conducting assessments of need for community based service and support and providing referrals.
  • Actively consulting and collaborating with hospital multidisciplinary team in planning and executing patient transitions.
  • Actively engaging patients and caregivers in the discharge planning process using valid and reliable instruments; including a discharge preparation checklist, personal health record, medication reconciliation process and plan for medical follow-up.
  • Directing engagement with patients and caregivers to complete the discharge preparation checklist, personal health record, medication reconciliation, as well as identification of educational needs in chronic disease process and self-management skills.
  • Visiting patient daily at hospital to ensure that patient and family are fully engaged and prepared for care transition process, including necessary tools and competency in self-management skills.
  • Providing additional coaching and education as necessary to assure transition is executed consistent with patient and caregiver goals.
  • Visiting patient within 48 hours of transition to home or other care setting to review care transition process including adhering with discharge preparation checklist, evaluating self-management skills, medication reconciliation, caregiver knowledge and self-management skills. Recognizing and addressing red flags and planning for medical contact and follow-up.
  • Establishing an ongoing plan for home visits and phone contacts specific to patient’s needs.
  • Tracking program and individual performance objectives and routinely reporting on progress and outcomes.
  • Actively participating in readmission reviews with hospital staff and health plans.
Bachelor’s degree from an accredited college/university in human services, plus a minimum of 6 months or more experience in transition coaching and/or 2 years of experience working with the geriatric population. The ideal candidate will be knowledgeable in geriatrics, with respect to home and community based services and social services and have experience working with chronically ill patients to identify patient goals and outcomes and provide education necessary for patient self-management. A candidate with a strong understanding of a coaching model with the ability to train others in this discipline and apply various coaching methodology to cases is also preferred. Strong communication skills, both oral and written are essential, as the Transitions Health Coach will be expected to interact and engage with participants/family members/caregivers/direct care workers in addition to working collaboratively with other health care professionals to assure coordination and continuity of patient care. To be successful in this role, the desired candidate should be highly organized, possess strong time management skills, be proficient in Microsoft Office products, including Word, Excel and PowerPoint and be able to work as part of a team as well as independently with minimal supervision. At times, this position will require work to be done during non-traditional hours on an as needed basis.Valid driver’s license and access to a reliable vehicle are required for local travel.

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