Care Transitions Manager

Position Summary

Assumes the responsibility and accountability for collaborating, directing, following and coordinating the care and services provided by the skilled nursing community to align with assigned resident’s goals as well as those of the acute and post-acute continuum care providers. This position is responsible for the effectively facilitating a successful transition from the skilled community into the home environment utilizing educational materials and support to encourage all stakeholders to play an active role in their total well being.

Assists the resident in becoming proficient and comfortable with managing their own care, providing guidance to the resident for effective care transitions, improved self management skills and enhanced provider to resident communication. The care transitions manager helps facilitate interdisciplinary communication and collaboration across multiple settings. Responsible for assisting the Director in managing an assigned number of team members to include providing coaching and training, corrective action planning, goal setting, interviewing applicants, and conducting performance appraisals.

Responsible for managing rehabilitation services including vendor management and relationships, team members rehab competencies and training. Acts as Director of Nursing in the manager’s absence.

Essential Duties

Coordinates the work of team members to meet resident goals and expectations. Performs post-admission screening to determine the resident’s level of current knowledge of the disease processes. Assesses resident baseline activation level using the PAM assessment to coach to improve score. Develops a coaching relationship with the resident and relevant stakeholders and empowers the resident to actively participate in the plan of care. Assists the resident in developing goals that are pertinent and measurable. Follows up with required communication, support and education with resident/family and team members to reduce the risk of readmission post discharge.

Coordinates and evaluates care conferences, care plan updates and Med A meetings including discharge plan and rehab and transition goals. Oversees discharge planning and case management. Implements all resident education materials and disease management teaching. Ensures effective communication both internally and externally to foster continuity of care. Evaluates resident readmissions and makes recommendations for QAPI. Implements INTERACT tools with staff to promote improved care practices, better communication and reports. Evaluates resident readmissions and makes recommendations for quality improvement practices.

Identifies residents in need of advanced care planning and initiates palliative/hospice care. Participates in the review of quality indicator reports and implements corrective action as necessary to include QAPI for hospital readmissions. May assist with clinical oversight as required. Responsible for encouraging, participating and…

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