What are the responsibilities and job description for the Transition Coach position at Thomas Jefferson University Hospital?
Job Details
Transition Coach
Job Description
Provides interventions to assure safe and effective care of patients diagnosed with heart failure. This will include primarily patients followed in the Heart Failure Center but may also include patients transitioning from the inpatient setting, rehabilitation facilities, skilled facilities, personal care facilities and home with home care as per the Hospital to Home (H2H) guidelines. Provides coaching to clients to enable them to gain disease self management skills and cope with transitions across care settings. Position includes both the main location of Abington with staffing of other Jefferson HF Clinic locations as needed.
- Meets all standards of the Patient Satisfaction Initiative Criteria in order to make Abington - Jefferson Health (AJH) the hospital of choice for Patients and Employees
- Provides triaging, telemanagement and telephone follow-up of heart failure patients in collaboration with the HF MD / APPs
- Provides education and support to patients and patient caregivers using 'Teach Back' process.
- Maintains active remote device monitoring ( e.g., CardioMEMs ), diagnostic results, Telehealth monitoring and Coumadin monitoring in collaboration with HF providers
- Maintains effective collaborative communication with multidisciplinary team members in maintaining quality care for the patient.
- Documents all care management activities for each patient / client in EMR
- Attends educational activities, quality improvement activities and departmental meetings as required
- Performs phlebotomy, IV catheter insertion, administers IV diuretics / IVF as ordered by HF providers, device interrogations, 6MWT, ReDs Vest monitoring in collaboration with HF providers
- Performs other duties as assigned.
Work Shift
Rotating (United States of America)
Worker Sub Type
Regular
Primary Location Address
1200 Old York Road, Abington, Pennsylvania, United States of America
Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic / programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.
