Transitions Coach

Aging Services of North Central Massachusetts provides comprehensive information and quality services so that older people, individuals with disabilities, and their families are empowered to make personalized choices to ensure a life of dignity, safety, and respect. The Transitions Coach provides transitional coaching to eligible patients in an effort to reduce the likelihood of an admission or readmission and create a smooth transition from hospital to home.

Requirements

• Participate in Coleman training and orientation sessions as assigned.
• Working knowledge and ability of I&R functions
• Telephonically outreach patients and/or meet patients at the hospital depending on contract specifications
• Conduct 2 to 3 additional follow-up phone calls to the patient within the 30-day post-emergency room visit or admission
• Identify required Support Services and provide them to the patient as appropriate
• Identify unmet community needs and provide referrals and resources as appropriate
• Participate in weekly meetings/rounds will be held with clinical staff to discuss the status and progress of enrolled patients
• When appropriate, request via email a 60- or 90-day extension of patient’s participation in the TIC Program
• Coordinate activities with other ASAP agency staff, including but not limited to: I&R Workers, Care Managers, Skills Trainers and Registered Nurses
• Document activities in progress notes, medical records, and Transition in Care database as appropriate
• Complete all documentation required for measuring quality and outcomes
• Participate in activities to assist and promote Central MA MetroWest Transitions in Care in gaining visibility and trust with Community agencies, hospitals, providers and the public
• Meet monthly targets including enrollments
• Screen patients for eligibility
• Complete requirements for hospital orientation which include obtaining and providing proof of certain vaccinations, PPD on an annual basis, drug screening, and not smoking
• Agree to follow the HIPAA regulations for each contract partner
• Other duties as assigned

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Retirement plan