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Transition Coach** **AdventHealth Shawnee Mission, Part-Time Days

All the benefits and perks you need for you and your family:

+ Vision, Medical & Dental Benefits from Day One

+ Student Loan Repayment Program

+ Received Magnet recognition from the American Nurses Credentialing Center in January 2019

Our promise to you:

Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better.

Schedule:** **Part Time, Days

**Shift** : 20 Hours per week

+ Monday (7 hours)

+ Wednesday (7 hours)

+ Friday (6 hours)

**Location:** AdventHealth Shawnee Mission AdventHealth Shawnee Mission

The community you'll be caring for:

At AdventHealth Shawnee Mission, formerly Shawnee Mission Medical Center, you're more than just a number on a chart. You're a whole person, who functions best when physically, emotionally, and spiritually fit. Find whole-person care, dedicated teams and staff, and a wide variety of medical services, all at our hospital in Shawnee Mission, Kansas.

The role you'll contribute:

The Transition Coach will implement the Shawnee Mission Health Readmission Prevention model targeted to reduce the number of patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. The Transition Coach will initially meet patients in the hospital and will follow selected patients who transition from the hospital to a lower level of care. Patients will be identified by various methods including the use of Cerner Quality Consoles, Care Coordination meetings and the BOOST tool. Strategies for patient management include but are not limited to Teach Back method of discharge instruction, assistance in setting up PCP appointment within 72 hours, home visits to assist with medication reconciliation and other self -management techniques, ongoing telephone follow up, assistance with psychosocial issues and gaps in service and support of caregivers as appropriate. Transition management will be provided to patients who discharge to a destination other than home and the strategies will be appropriate to that level of care. The Transition Coach will work as part of an interdisciplinary Transitions Team including acute care case managers, social workers, home care liaisons, physicians, pharmacists, nursing leadership and staff nursing. This position will also work as part of various other teams, including the Continuing Care Team on each unit. The Transition Coach will also participate in routine readmission meetings with community partners as well as comply with data collection expectation

The value you'll bring to the team:

+ Identifies patients with moderate to high-risk conditions for readmission and collaborates with the treatment team to ensure safe and effective transitions of care.

+ Assesses, educates, and provides interventions for patients and families in disease self-management both during the hospital stay and post discharge.

+ Assesses medication adherence and regimen and provides education with interventions to improve the patients medication compliance.

+ Coordinates care of patients at risk for readmission from discharge through 30-90 days post discharge.

+ Arranges post-acute resources for patients requiring additional support post-discharge from the hospital.

Qualifications

The expertise and experiences you'll need to succeed** **:

+ 1 Work Experience Required

+ Registered Nurse (RN) Kansas Required **or**

+ LMSW

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Case Management

**Organization:** AdventHealth Shawnee Mission

**Schedule:** Part-time

**Shift:** 1 - Day

**Req ID:** 25044297

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.