Description: The Transition Coach helps hospital patients avoid re-hospitalization within 30 days of discharge. The Transition Coach uses the Coleman Care Transition Model to build the capacity of the patient to manage their health care, communicate with health professionals & use community resources as needed. Responsibilities: • Collaborate with Hospital staff on choosing appropriate patients for referrals Collect referrals from Hospital staff on a daily basis. • Use the Coleman Care Transition Intervention (CTI) model to build the capacity of the patient to avoid re-hospitalization: - Make initial contact with referred client in the Hospital setting prior to hospital discharge. -Conduct home visit with client within 72 hours of hospital discharge. Build client capacities in medication self-management, use of patient-centered health records and following discharge instructions, and document follow-up with medical personnel. - Provide 3 monitoring calls to patient over a period of 30 days after hospital discharge to provide additional coaching and offer linkages to other community providers as needed. Transition Coach will provide monitoring calls (approximately 2-3 calls) to patient within 30 days of hospital discharge to provide additional coaching and offer linkages to other community providers as needed such as Case Management, Mental Health Services, Transportation, ESL programs etc. • Monitor, enter data and report on CCTP program enrollment and patient interventions. The Transition Coach will utilize the DFTA Senior Participate Profile database (SPP). • Attend meetings with other members of the Queens Collaborative, and other meetings as scheduled. • Conduct presentations before hospital staff, community groups, social service agency staff. • Attend webinars scheduled by Center for Medicare and Medicaid Services. • Attend meetings of the CCTP Queens Collaborative. • Other tasks as assigned.
|Type of Opportunity||Full Time, Part Time|
|Field of Study||Nursing|
|Special Skills & Requirements||Qualifications: • Bachelor's preferred or some college with 3 or more years of experience working with seniors in a coaching capacity or health care setting • Good verbal & written communication skills • Access to a vehicle to make home visits • Bilingual in Spanish preferred • Ability to work independently • Knowledge of health care settings preferred • Computer skills - Word, excel and ability to use the program’s database. • Experience working with the elderly • Ability to collect, track & record data PHYSICAL REQUIREMENTS: • Able to climb stairs and make home visits • Able to travel to different location to attend meetings and training • Able to stretch and bend to retrieve files • Able to sit and work on the computer for long periods of time • Frequent walking, sitting, talking and hearing • Occasional climbing, balancing, stooping, kneeling and crouching • Ability to read printed materials and computer screens • Able to write • Must submit annual physical indicating a negative PPD result. • Must agree to submit to drug testing in accordance with Jamaica Hospital’s HR policies|
|Company Name||Catholic Charities Neighborhood Services|
|About the Company:||Catholic Charities Brooklyn and Queens promotes unity among all persons by seeking to develop caring communities. Our more than 160 programs provide affordable housing, nutritious meals, recreation for seniors, residences for the developmentally disabled, and assistance to neighbors in need.|
|Website:||Barbara Kelly, LMSW|
|How To Apply:||Contact Barbara Kelly, LMSW at firstname.lastname@example.org|