Yale New Haven Health System

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Transitional Care LPN is a member of the Enterprise Office of Population Healths Ambulatory Care Management team and is accountable for improving the health outcomes of the populations being managed. The Transitional Care LPN works as part of a multi-disciplinary team under the direction of the Ambulatory Care Management leadership. The Transitional Care LPN is responsible for Transitions of Care (TOC) / Transitional Care Management (TCM) follow-up for patients transitioning between phases on the continuum of care, including but not limited to patient's post-hospital discharge. The role includes performing post-hospital discharge calls, ED discharge follow-up calls, and post-acute transition calls, as applicable, and providing other transitional care support including ensuring timely follow-up appointments and logistics pertaining to obtaining medications. This role will work closely with RN Chronic Care Managers to enroll patients in Chronic Condition Management (CCM) if a patient is eligible and would benefit from the program.

EEO/AA/Disability/Veteran

Responsibilities

• 1. Performs post-hospital discharge and post-ED visit phone calls under the supervision of a licensed RN.
• 2. Works to reduce the readmission and unnecessary Emergency Department visits.
  • 2.1 As part of the interdisciplinary health care team, the LPN position performs post-discharge interviews and collects, reports, and records subjective and objective patient-related data.
• 3. Identifies and reports existing barriers to health equity and assists with the management of barriers or referrals to community resources including facilitation of transportation needs.
  • 3.1 Engages patients and/or caregiver regarding care needs by validating awareness and understanding of post-acute discharge plan(s) including but not limited to review of discharge instructions, medication adherence, and reinforces the importance of compliance with prescribed medications and treatments.
• 4. Ensures scheduling and patient ability to attend follow-up appointments.
  • 4.1. Identifies need for and facilitates appropriate routing of referrals under the direction of RN licensed staff which links patients to available resources and services needed.
  • 4.2. The ability to pull daily EHR reports to include various filters: i.e. discharge reports as recommended.
  • 4.3. Escalates any issues requiring clinical decision-making or clinical assessment to the RN or RN leadership.
• 5. Guides patients to the most appropriate level of care for the safest medical management.
  • 5.1. Educates patients on recognizing signs of complications or worsening symptoms.
  • 5.2. Provides educational tools to patients and/or community services as requested.
• 6. Educates patients and families on all components of a safe discharge, and best practices to avoid readmissions, manage disease states, and attain optimal wellness.
  • 6.1. Offers emotional support and encouragement during recovery.
  • 6.2. Documents telephonic interaction per the standard of the department.
• 7. Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team.
  • 7.1. Assists the Care Management team to evaluate and redirect the current patient plan of care in order to streamline the delivery of service.
  • 7.2. Contacts and coordinates with referral agencies to arrange the provision of ordered equipment and associated services when appropriate and as directed by the Care Management team.
  • 7.3. Able to relate and communicate positively, effectively, and professionally with others able to demonstrate positive customer service skills work calmly and respond courteously when under pressure.
• 8. Performs other duties as required or requested.

Qualifications

EDUCATION

High school diploma required. Graduate from an accredited LPN program required. Current LPN license in the State of Connecticut required.

EXPERIENCE

3 years of clinical experience in direct patient care. Case management experience in an acute, community, or post-acute provider or health plan experience preferred.

LICENSURE

Current LPN licensure from the State of Connecticut required.

SPECIAL SKILLS

Motivational interviewing skills necessary. Excellent verbal and written communication skills. Possesses excellent organizational skills and ability to handle multiple priorities. Ability to work in an independent role with minimal supervision. Functions as an integral team member and demonstrates flexibility in sharing responsibilities. Validated translation capability preferred. Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed.

PHYSICAL DEMAND

Role is primarily a remote work position with the ability and expectation to travel to onsite practice locations from time to time as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards.

YNHHS Requisition ID

161518