Transitions Coach

Job Description

Job Description

Description:

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 values of ASNCM have been determined by its employees and is the foundation of our culture.

Collaboration – we communicate and coordinate with others, internally and externally, to make a positive difference for our consumers and their families.

Compassion – we work with “heart” to be kind, caring and willing to help our consumers in their journey.

Consumer-Centric - we are committed and persistent in ensuring that our services and experiences are of high quality, resulting in positive consumer impacts.

Empowerment - we strive to make our consumers stronger and more confident to control their lives with personalized choices and claim their rights to a life of safety, dignity, and respect.

Integrity – we adhere to the highest standards of professionalism, ethics and personal responsibility, worthy of the trust our consumers place in us.

GENERAL DESCRIPTION:

To provide 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.

• 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. Provide each patient with a minimum of 1-in-home in-person visit within 7 days of discharge or referral. The intervention will focus on 4 key elements of the Care Transition Intervention (CTI) Model.
• Conduct 2 to 3 additional follow-up phone calls to the patient within the 30-day post-emergency room visit or admission emphasizing the elements discussed in the previous in-home in-person visits.
• 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.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

A bachelor’s degree in human services, health, or a management-related field is preferred. A minimum of two years’ experience in a social service setting is required. Strong knowledge of long-term care and social service systems, community resources, and local service systems, particularly experience working with older adults and individuals with disabilities is required.

The ideal candidate will have the ability:

• To independently organize work and meet deadlines.
• To multi-task in a busy environment
• To manage constant change with a positive attitude
• To articulate program needs and goals and make public presentations.
• To positively influence others to achieve results that are in the best interest of the organization.
• Must be proficient in Microsoft Office

A valid driver's license and a legally insured and registered motor vehicle are required, a copy of current license and registration will be on file in the personnel record.

ESSENTIAL FUNCTIONS:

PHYSICAL

Sufficient clarity of speech and hearing which permits communication with supervisor, co-workers, consumers, community professionals, and general public.

Ability to talk on a phone, stand, walk, sit, and travel in the community.

Ability to travel throughout the state of Massachusetts in a private vehicle under all weather conditions including snow.

Ability to express ideas concisely and clearly, orally and in writing.

Sufficient vision which permits production and review of a wide variety of materials, written correspondence, reports and related electronic and paper communication.

Ability to lift and carry objects weighing 20 pounds.

Ability to read and analyze data.

Ability to exercise sound judgment in making decisions.

MENTAL:

Capacity to deal rationally and calmly with varying personalities

Capacity to work well in fast paced, rapidly changing environment.

ENVIRONMENTAL:

Must be able to tolerate by-products of office machine operation.

This position is an onsite role.