Address
Form of workEnsures patient receives post-acute care from high value network providers, and follow up appointments are scheduled.
The Patient Care Navigator (PCN) readies the patient for discharge and ensures that all patients are provided transition to the best setting for post-acute care based on their specific needs. The PCN educates patients/families on the post-acute care plan and expectation after discharge, helps them preference their best facility or service for care after discharge, and keeps a relationship with the patient/family after discharge.
Within 24 hours of admission
Receive and review patient post-acute care plan
Meet with patient/family
Throughout patient stay:
Educate patient/family on post-acute care plan, expectations of post-discharge realities
Coordinate discharge teaching with care team
Regularly connect with the patient's interdisciplinary care team
Communicate discharge plans with Care Navigation Center
Review financial respoinsibility with patient/family
Tailor care to patient clinical and psychosocial needs
Post-Acute facility/service and physician preferencing based on patient/family needs and goals; educates patient/family on CMS quality measures
Coordinates activities to ensure patient's appeal rights under Notification of Hospital Discharge Appeal Rights
Upon discharge:
Confirm discharge orders
Discuss follow-up plan with family
Appointment/follow-up scheduling
Ensure DC papaerwork (prescriptions/DME/referral forms/signatures) ready for discharge
After discharge:
Patient follow-up call within 24 hours, continued contact based on evidence based decision tools
Medication adherence
Escalation to clinical team and post discharge issues for appropriate intervention and resolution
Education:
Associate degree in relevant clinical area required. Bachelor degree in relevant clinical area and/or health degree preferred.
Experience & Knowledge:
2 Years' experience in clinical area required. 1 year in post-acute setting preferred
Effective communication skills
Understand all levels of post-acute care, hospital, and physician regulations
Ability to manage multiple processes simultaneously
Special Skills & Equipment Knowledge:
Experience in transitions of care
Computer competency
Multi-tasks and prioritizes work
Teaching skills
Communicates effectively with persons of various backgrounds (oral and written)
Maintains a calm, professional demeanor when dealing with internal and external contacts
Familiarity with area providers and services a plus
