Overview:

VNA Health at Home has provided home care and wellness services for over 130 years. Our innovative services and specialty programs recognize the needs of each patient and promote the highest quality of life. Our goal is to ensure all services consistently exceed quality measures and the expectations of patients and referring physicians. VNA Health at Home's quality care is provided through a team of registered nurses, social workers, aides and physical, occupational and speech therapists.

Responsibilities

The Care Transition I (CTN) collaborates with physicians, hospitals, nursing homes, home care and hospice personnel in the process of providing coordinated quality home care services for patients referred to CommonSpirit Health at Home. Increases awareness among key contacts at health care facilities when home care and/or hospice is an optimal solution and helps identify when services are appropriate for individual patients. Assists patients in making a seamless transition to home care.

Responsibilities

• Completes and submits all required documentation in an accurate and timely manner.
• Presents patient with home care and/or hospice agencies and obtains patient's signed home care and/or hospice choice form.
• Arranges home care/hospice services for patients regardless of agency selected.
• Follows referral of a patient to the organization, assists discharge coordinators in coordinating quality home care/hospice services for patients in the following manner:
• Determines patient eligibility for home care/hospice services.
• Effectively communicates with appropriate disciplines involved in the care of potential home care/hospice patients, and provides information and recommendations to organization staff.
• Develops professional working relationships with health care providers and facilities, generating an open flow of information and support of home care/hospice goals; provides value added counsel, teaching and resourceful problem solving.
• Available to all discharge planners, physicians, other hospital personnel and patients to:
• Analyze eligibility for home care/hospice provide general guidance in determining if a patient would benefit from home care/hospice services.
• Explain Medicare and Medicaid guidelines, insurance plan benefits, financing options organization policies, etc.
• Upon patient choice of services, communicates with attending physicians to obtain verbal or written orders for home care services.
• Assists in ordering equipment, oxygen, IV's, etc., as required to provide proper home care/hospice for the patient referred to the company.
• Provides general home care/hospice education to patients, caregivers and others as requested by referral sources.
• When requested, participates in the education of providers and personnel on home care regulations and the variety of services available as well as industry trends.
• Promotes effective working relationships with nursing personnel, the management team, and health care providers.
• Works independently with limited direct supervision using the guidelines of the Nurse Practice Act, organizational and department policy and procedures, and professional judgment.

Qualifications

Qualifications

Graduate of an accredited school of nursing.

Current RN or LPN license to practice in the state serviced.

Obtain and maintain current CPR certification.

Knowledge of home care regulations are required.

Two years of hospital nursing experience required; additional home care experience preferred.

Prior experience as a Care Transition Nurse or sales experience preferred.

Strong assessment, critical thinking, judgment, creativity and decision making skills are required.

Must possess excellent interpersonal, training, customer service and persuasiveness competencies; listens, gains respect, develops trust and acceptance of ideas; able to assertively build a network of referrals,Emotional composure, maintains professionalism.