BASIC FUNCTION AND RESPONSIBILITY

The Home Care Admission Coordinator is responsible for the planning of integrated home care services; including interpreting and communicating the eligibility of patients to receive home nursing and ancillary services; and assessing the home nursing and ancillary needs, including the physical, psychosocial and environmental needs, of patients and their families while they are transitioning from or to acute settings, thereby facilitating the smooth transition of patients.  The Home Care Admission Coordinator will receive referrals and will make direct contact with patients and providers as appropriate. 

CHARACTERISTICS DUTIES AND RESPONSIBILITIES

Confers with acute care staff, discharge planning and patient/family to determine the most appropriate timing of hospital discharge and home care admission.
Communicates with the patient/family regarding physician’s plan of treatment and the role of home care.
Serves as a liaison between hospital and field staff providing field staff with accurate and timely post-discharge referral information for both readmitted patients and new referrals.
May participate in multidisciplinary patient rounds as needed.
Assesses, plans and implements continuing patient care needs post referral, including home care and other community care resources to meet pre and/or post acute care intervention.  Planning may include continuing or substitutive interventions (e.g., post hospital care or care in lieu of hospitalization). 
Provides information to patients, families, and the health care team regarding patient care options for post-discharge needs in a positive and effective manner. 
Serves as a member of the multidisciplinary team to ensure continuity of care and the implementation of an appropriate plan of treatment.
Ensures patients are eligible for home care services and meet program guidelines.
Initiates and completes comprehensive nursing assessments to identify the physical, psychosocial, behavioral and environmental needs of the patient as required.
Initiates home care admission and plan of treatment with the patient while in the inpatient setting as appropriate.
Works closely with MVN intake and supervisory staff to coordinate the admission of the patient to home care service.
Verifies and communicates with the follow-up physician as needed.
Communicates with infusion providers to clarify patient education needs and level of knowledge prior to hospital discharge.
Works with the multidisciplinary team to verify payer source.
Collects data to facilitate patient care and evaluation as indicated.
Demonstrates desired results in achievement of all relevant strategic, budgetary and operational targets and objectives including, but not limited to revenue, expense, utilization and quality indicators.
Adheres to all infection control and safety procedures which are in agency policies and procedures.
Attends scheduled agency meetings and inservices.
Accountable for using all equipment and technology (i.e., cellular phones, point of care devices, computers, etc.) according to agency policy.
Takes responsibility for working knowledge of agency policies and procedures, including the agency Compliance Program.
Understands and applies compliance policies in day-to-day operation.
Handles special assignments as directed by their supervisor. (e.g., may be assigned to do patient home assessment or collect data for special projects, etc.).
Participates in agency committees and work teams as assigned.
Presents and conducts self in a professional manner and according to agency policy.
Communicates and interacts appropriately with coworkers and supervisors.
Interprets and promotes the agency mission, programs and policies as appropriate to patients and the community.
Participates in agency sponsored educational and health programs and activities

SUPERVISION RECEIVED

Supervision is received from a Patient Care Services manager.

QUALIFICATIONS

Successful completion of a program in nursing is necessary.
Current licensure as a Registered Nurse in the State of Michigan is necessary.
Bachelors degree in Nursing is necessary.
Demonstrated knowledge of home care practices and reimbursement is necessary.
Two years of recent clinical experience in a home care setting is necessary.
One year of recent clinical or managerial experience which demonstrates effective coordination of clinical care for a range of high risk or complex patients is necessary.
Ability to work autonomously as well as collaboratively with other disciplines in the care management for identified patients is necessary.
Demonstrated skill in computer applications is necessary.
This classification requires Primary Source Verification.

DESIRED QUALIFICATIONS

Master’s Degree in Nursing (MSN).
3-5 years of recent clinical experience in an acute or home care setting.
Demonstrated knowledge of the continuous quality improvement process (Plan-Do-Check-Act).