HCA, Hospital Corporation of America Transitional Care Coach Registered Nurse (RN) PRN in Austin, Texas

_POSITION SUMMARY_: The transitional care coach serves asthe bridge between the professional staff in a care setting (e.g. hospital) and thepatient and/or family/caregiver and plays an active role in promoting ongoing management of their health care. The coach facilitates interdisciplinary collaboration and care continuity across care settings. Thecoach focuses on high needs/high risk clients, provides transition support services, generally based upon the Coleman model Care Transition Intervention (CTI®) to facilitate effective care transitions, improved self-management skills, and enhanced client-provider communication. _ _ _ESSENTIAL JOB RESPONSIBILITIES_:

· Perform admission visit at hospital, developing the coaching relationship, empowering the patient to take an active, informed role in their discharge planning and introducing the patient-centered personal health record.
  • Work with nursing staff, physicians, case managers, skilled nursing facility staff, and staff at the client’s medical home, on implementing services and on disposition of cases.
  • Coach the patient in building confidence and competence in four key areas: medication self-management, use of a patient-centered health record, primary care andspecialist follow-up and knowledge of red flags of their condition and how to respond.
  • Perform five follow-up phone calls to the patient, on or about 72 hours post discharge from acute care, second call within 7 days of discharge and then weekly thereafter.
  • Track coach-related metrics and report on intervention progress.
  • Identify and address barriers to accessing health care and social services.
  • Provide advocacy and serve as a resource forthepatient and/or family/caregiverto community long-term services and supports, such as family caregiver programs, nutrition programs, in-home care, and case management.
  • Provide teaching about self-management of the client’s chronic disease and link with ongoing chronic disease management support services.
  • Develop and maintain linkages with community agencies and organizations that could give support to the program or individual persons.
  • Work collaboratively with multi-disciplinary team, including but not limited to nurses, case managers, and physicians.
  • Participate in continuing education and training programs.
  • Act as a liaison through effective and professional communications between and with physicians, patient/family or caregiver, hospital staff, and outside agencies.
  • Demonstrate knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives; monitor self-compliance and implement process changes to ensure compliance to such regulations and quality initiatives as it relates to the provision of care transitions.
  • Assume a leadership role in the development, revision, and implementation of clinical protocols which transition patients across the continuum of care or discharge patients to an appropriate service level of care. · Track and trend variances to care and barriers to care; makes recommendations and develops action plans to improve processes and systems · Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely.

    **This is not necessarily an extensive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or require that other or different tasks be performed when circumstances change (i.e. emergencies, changes in personnel, workload, rush jobs or technical developments).

_KNOWLEDGE, SKILLS AND ABILITIES_: * Ability to establish and maintain collaborative and effective working relationships * Ability to communicate effectively in oral, written and electronic formats * Demonstrates analytical and critical thinking abilities with pro-active decision-making and negotiation skills * Demonstrates and ability to perform specific competencies as identified * Basic typing skills, 30 wpm; * Basic personal computer skills; * Positive, enthusiastic, helpful personality; * Customer service oriented;


Required: AssociateorBachelor’sdegreeinNursing. * Threeyears nursing experience in acute care setting preferred.


Required: Current license to practice as a Registered Nurse in Texas.

Preferred: Experience in Case Management, Disease Management, or Transitional Care

Title: Transitional Care Coach Registered Nurse (RN) PRN

Location: Texas-Austin-Partnership Market Office

Requisition ID: 06766-49292