Transitional Planners identify, assess, plan, and evaluate the needs of patients for discharge and transitions of care. Transitional Planners collaborate with Providers, nursing and the entire multi-disciplinary team to transfer the patient to the appropriate level of care across the care continuum. Transition Planners assist the patient, family members and/or any caregivers who have an ongoing caring relationship with the patient to determine the most appropriate level of care and make referrals to the facilities and services deemed necessary.
DUTIES AND RESPONSIBILITIES:
Educates patients, families, Providers and hospital staff about community care services/resources and eligibility criteria.
Coordinates patient transition/discharge to designated facilities or community care services; acting as a liaison between the Patient/family, Provider, facility, and the community agency or service line.
Will be responsible for communication and hand offs to the next level of care to ensure a smooth transition. Hand offs could include: verbal phone report and/or faxing of pertinent information to the next level of care provider. Items should include but are not limited to: Demographics, History & Physical, Discharge Summary, Discharge Orders and Medication Reconciliation, PT/OT/Rehab notes, and any other pertinent information that could impact patient care at the next level of care provider.
Demonstrates competency in the referral of individualized care needs of patients to the appropriate care service based on age, developmental needs, payor source, and necessary criteria.
Coordinates communication to achieve (patient, family, and physician) satisfaction while facilitating an appropriate, efficient, and cost effective discharge.
Assists in identifying and documenting avoidable delay days attributed to the following categories: Delay in Discharge; Delay in Treatment or Diagnosis; Care Management; Medical Staff/Physician; Discharge Planning.
Will incorporate and utilize LACE scores and GMLOS when coordinating transition planning to the next level of care.
Actively participates in weekly Complex Case Review meetings by providing valuable and relevant updates on patient status and next steps for the patient's continuum of care.
Must be able to identify the discharge appropriate level of care for patients such as but not limited to: Skilled Nursing, Home Care, Transitional Care, Rehab, Hospice, Palliative Care, and/or private duty. Must have the ability to arrange medical equipment, transportation, outpatient therapies, and Primary Care Provider follow up while coordinating with the patient/family, Provider and community agencies to assure smooth transition.
Monitors delivery of care by completing patient rounds with Utilization Review RN; documenting care; identifying progress toward desired discharge outcomes; intervening to overcome deviations in the expected discharge plan of care; reviewing the care plan with patients in conjunction with the direct care providers; interacting with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults; reporting personnel and performance issues to the unit manager; maintaining ongoing communication with Utilization Review RN team regarding variances from the care plan or transfer/discharge plan.
Act as a liaison between facilities and maintains effective public relations between the hospital facilities and community agencies.
Perform chart reviews, patient assessments, interview staff/Provider, and patient/family, to make thorough and appropriate community referrals.
Generate and cultivate referrals based on patient needs and choice and comfort of acting independently.
Possess understanding of national healthcare regulations and financial impacts and educate multidisciplinary team members and patient/family.
Perform other job related duties and assigned tasks as requested; which may include: cross training and/or other job functions as temporary work loads and volumes require.
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrate the ability to deal with a variety of people, deal with stressful situations, and handle conflict. Orients and educates patients and their families by meeting them; explaining the role of the Transition Planner; participates in care planning, and documents continuing care requirements.
Participates in interdisciplinary care planning; and coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; fostering peer support; providing education to others regarding the care management process.
Contributes to team effort by accomplishing safe and efficient discharge outcomes.
Attends care rounds.
Utilizes designation of choice forms.
Completes all Transition Planning Assessments within 24 hours of admission excluding holidays and weekends.
Educates patients and families on available community resources.
Participates in care conferences with multi-disciplinary team.
Assesses complex social situations or resource needs.
Aware of Length of Stay and cover days from URRN..
Provides and explains as required the Medicare Observation and Outpatient Notification (MOON) letter and/or the Medicare Most Important Inpatient notification letter.
Assists clinical and support staff to make patient follow-up appointments as required.
Validates discharge education/documents are completed/medication scripts sent to pharmacy, "Live Well" Binder updated and given to patient.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.
Graduate of an accredited college or university with a BS or Associates degree in nursing, social humanities or related field required.
Three to 5 years of nursing clinical experience, discharge planning or social work experience preferred.
As a not-for-profit community health system, Benefis is driven to provide the highest level of care. We serve nearly 230,000 residents across a 15-county region that is bigger than Connecticut, Massachusetts, New Hampshire and Vermont combined. Benefis is the largest non-governmental employer in the Great Falls area, with more than 3,000 employees.Benefis has 530 licensed beds (that includes 146 beds in long-term care, 71 in assisted living and 20 beds at Peace Hospice of Montana) and partners with over 250 area physicians.Our hospital has been recognized for its exceptional work in quality care by providing a wide range of programs and services to help you live the best life possible. We’re here to help you “Live well.”Benefis Health System came about when two Christian-based hospitals became one. Our founders believed in providing good care to all in need, and trusted that this would be accomplished. The Benefis name was derived using Latin root words: "Bene-" meaning good, and "fis-" for faith and trust. It’s these same root words that make up such terms as ‘beneficial’ and ‘confidence’.Benefis has been a trusted provider of care for more than 125 years. And our name speaks to o...ur commitment: good care one can put faith in.Benefis is consistently ranked among America’s top hospitals by the nation’s leading healthcare ratings organizations for a range of services, including cancer care, joint replacement, stroke treatment, wound care and home health.To learn more about our services, continue looking through our website at WWW.BENEFIS.ORG or call 406.455.5000.