Lafayette General Health
To coordinate the care between acute and post-acute providers by empowering patients and encouraging those to be involved in their own health care therefore facilitating patient accountability in the safe transition of care and ensuring positive quality outcomes, with a focus on reducing unnecessary hospital readmissions.
Responsible for the development, implementation, auditing and analysis of the Readmission Prevention Program hospital-wide.
Routinely develops data presentations for Physician and Healthcare professional, with analysis and recommendations for Readmission Reduction.
Screens and contacts patients that are eligible for Program.
Enrolls patient in the Program and provides necessary coaching to reduce or eliminate high risk behavior leading to hospital readmission.
Provides patient education and encourages habits that are conducive to a high quality of life.
- Provide enrolled patients with tools to facilitate compliance with plan of care in post-acute setting, when appropriate.
- Provide consultation to patients and their family to prevent readmissions.
Assess patients social background, housing, and family situation and foster an environment of individual responsibility.
- Interview patient to assess their goals for their plan of care.
- Monitors patients progress towards goals for 30 days post hospital discharge.
Coordinates hospital care with case management, attending MD (to include receiving and documenting physician orders as necessary for patient care), consulting physicians, nursing, PT/OT/ST, dietary and pharmacy and follow a customized plan of care established by the team with goals and action plans.
Participates on teams, workshops, task forces, pilot programs, and special projects as needed.
- Collects, trends, analyzes, and reports readmission data for appropriate patient populations.
- Presents data and analysis to physicians and other healthcare professional at Medical Staff Meetings.
- Makes recommendations during data reporting for opportunities regarding readmission prevention.
Supervises the timely completion of Core Measure Indicators on the patient population in the program which reduces the potential monetary penalties of the hospital.
Supervises the timely completion of Core Measure Indicators on the patient population not in the program as time allows.
Assists with nursing care to meet Core Measure compliance on patient in the program as needed and appropriate to include such nursing duties as vaccine and medication administration.
Assists with nursing admission and discharge documentation on the patient population in the program as needed.
- Updates patients home medication list in EMR as appropriate to ensure accuracy.
- Consults with physicians to review and correct medication discrepancies.
Discusses end-of-life issues and available options for patient/their family, when appropriate.
- Provide Advanced Care Planning.
- Encourage completion of advanced directives/living wills/LaPost by patients who are appropriate.
Patient advocate to ensure patient goals are respected and followed through during course of care.
Assists with improving communication among the care team inpatient and post-discharge to help close gaps in patient care that may exist.
Available as a resource to hospital staff (including physicians) for recommendations on readmission prevention.
- Reaches out to attending physician and/or nurse regarding identification of readmission risk factors and possible prevention.
Arranges for Discharge Planning via:
- Establishes a relationship and good rapport with the patient.
- Makes appropriate resource referrals; including, but not limited to, palliative team and different levels of post-acute care.
- Reviews discharge medication reconciliation and coordinates when appropriate.
- Educates regarding medication, side effects, diet, diagnosis, what to expect, etc.
- Provides resources for medication assistance when needed and when appropriate or collaborates with case management to provide resources.
- Ensures that the patient has scheduled and attended a follow-up appointment with MD.
- Provides a copy of the discharge summary, medication changes, and all medical information related to admission to the attending MD.
Participates in Post-Discharge via:
- Follows up with patient via phone within 2-3 days post discharge to assess patients condition.
- Assesses patients understanding of and compliance with discharge medications within 2-3 days post discharge (via phone).
- Provides education and advice as needed.
- Conducts weekly phone calls with the patient up to and/or beyond 30 days post discharge to educate and advise on follow-up care and reduce readmission within 30 days.
- Encourages patient to attend all scheduled follow-up appointments with physician(s).
- Encourages compliance with plan of care.
- Assists patient in identifying when to notify their physician about changes in signs/symptoms of their disease process.
- Coordinates care among patient/family, post-acute providers, and physician(s) post-discharge to prevent return to acute care setting.
Documents pertinent information in patients EMR as appropriate.
- R.N. required and licensed in the State of Louisiana.
- Prefer a minimum of 5 years of clinical work experience.
- Knowledge of regulatory agencies
- Extensive computer knowledge is required
- Excellent analytical skills to compile and present data to professional with recommendations for improvement
- Strong interpersonal and communication skills
* Health Coach Certification to be obtained within 2 years of hire
PHYSICAL DEMANDS AND WORKING CONDITIONS:
Medium Work as defined by the U.S. Department of Labor constitutes a maximum lift of 21-50 pounds on occasion and/or a maximum lift of 11-25 pounds on a frequent basis
May be required to assist in the turning, lifting, or moving patients as well as walking about from patients rooms, as well as to and from various hospital areas
Formal application; verification of education, and experience; verification of license(s), certification(s), registration(s), accreditation(s) if applicable; oral interview, reference and background checks; job related tests may be required.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must comply with all SERVICE Standards of Behavior