Job Description
Coordinates hospital/emergency room follow-up services for patients. Conducts patient assessments and supports care planning, coordination, and advocacy efforts to ensure continuity of care. Provides non-clinical education, wellness resources, and assistance connecting patients with appropriate community and clinic-based services. Maintains familiarity with VNA programs and services to support office operations and deliver comprehensive care coordination for diverse patient populations. While primarily responsible for supporting patients of VNA Health Center, this role also receives cross-training in the following areas to provide team coverage and operational support as needed. This position includes onsite coverage responsibilities at local area hospitals. Coordinates hospital and emergency department follow up care. Serves as a liaison between VNA inpatients at the hospital and the VNA clinic to coordinate patient primary care services. Face to face patient contact at hospitals, clinics and patient homes as indicated. Communicates with hospitals and on-call staff to track patient hospitalization, status and discharge information. Participates in hospital “care team” meetings to present VNA information regarding services, health plan participation and program updates. Meets all VNA and hospital credentialing criteria for hospital rounding. Rounds on all postpartum/newborn and hospital inpatients daily, or as indicated and prepares parents of newborns for child's first appointment. Coordinate clinic follow up appointments for patients by ensuring appointments at the clinic are made prior to discharge from the hospital, if possible. Ensure discharge summary, test results, etc. are available for providers at follow up appointments. Inform patient of available resources and assist the patient in making appointments as needed. Refers patient/Family to RN for health education materials and coordinates patient health education through community resources. Provides patient education materials to promote patient compliance. Coordinates services to ensure screenings are completed, and coordinates care to higher level depending on results. Inform patient of available resources and assist the patient in making appointments as needed. Evaluates effectiveness of health education, wellness-screening reminders and coordinates additional education and care as needed. Assists with Home Health/Hospice intake process by following up with patient referrals from various hospitals and their referral platform to determine eligibility for Home Health/Hospice services. Follows work flow and completes intake process to prepare patient for admission to VNA. Tracks and documents information about effectiveness of care and outcomes of referrals. Understands and practices exposure control procedures as well as patient safety. High school diploma required.Some college preferred. Bi-lingual in Spanish/English as follows: Reading - Required. Written - Required. Speaking - Required. Effective organization and communication skills, including neat and legible hand writing/printing. Community health experience preferred. Maintains current CPR certification. Excellent computer skills required.Good working knowledge of Microsoft Office software, especially Word and Excel. Health policies and requirements met (See Personnel Policies). Essential Functions/Physical Requirements: