Full Time 40 hours Grade 044 Home Care Liaison Responsibilities General Purpose: The role of the Acute Care Coordinator is to serve as an adjunct to the multidisciplinary team. The Care Coordinator, in partnership with unit staff (nursing, providers, consulting services, social work, etc.) and providers caring for the patient at discharge, assists in facilitating a patient focused plan of care aimed at ensuring a safe transition from hospital to home for adult acute care patients. Responsibilities: Coordinate care of patients in acute care. Assume coordination role at the point of admission and through discharge with targeted coordination and follow-up. Identify patient discharge needs. Assist in implementing patient care strategies to close gaps in medical care upon discharge. Identify resources for patient self-management planning and discharge. Assist in developing and implementing care plans for medically complex patients. Identify barriers to a successful discharge plan. Coordinate use of clinical and ancillary resources within and outside of the health system to achieve treatment goals specified in the patient care plan and facilities discharge. Participate in development of discharge plan with short- and long-range care plan goals for patients. Keep abreast of organizational developments and practices that may impact operations by participating in continuing education courses, professional organizations and seminars, reading current literature, and maintaining professional contacts in the community. Assist with the development of current evidence-based protocols, policies, work flow and flow sheets, guidelines, etc. related to the provision of care within the acute care coordinator, RN model. Participate in committees as assigned. Interact effectively with physicians, the acute care coordinator team, and patients and their caregivers. Manage patient discharge process. Adhere to infection control and safety guidelines. Adhere to HIPAA, TJC, CMS, and OSHA regulations and policies. Attend bi-weekly acute care coordinator and patient family services meetings as scheduled. Other duties as assigned. Qualifications: Associate of Applied Science in Nursing and a minimum of five years of professional nursing experience. BS/MS and acute care, community health, care management, and/or disease management, multidisciplinary team experience preferred; or an equivalent combination of education and experience. New York State registration
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