Care Transitions Health Coach

Job Overview:

The Care Transitions Health Coach is responsible for providing services to eligible patients aimed at preventing hospital readmissions. This role emphasizes empowering patients to manage their chronic conditions through education, self-advocacy, and guidance on navigating complex healthcare systems. The Health Coach ensures patients are informed about available supports and services through The Span Center and facilitates necessary referrals to community partners. This role also includes supporting and the implementation of the MVP program by providing intensive, relationship-based support to adults with frequent hospital admissions or emergency department use. The CT Coach serves as the primary point of accountability, helping stabilize medical, behavioral health, and social needs through home visits, care coordination, and system navigation. This approach emphasizes engagement, trust-building, and problem-solving, rather than short-term discharge planning.

Supervision:

Performs work under the direct supervision of the Care Transitions Program Manager.

Duties/Responsibilities:

• Receives Care Transitions referrals directly from referral source.
• Assess patients for eligibility in the Care Transitions program by reviewing medical records, consulting with hospital care coordinators and social workers or other medical personnel and conducting patient interviews.
• Facilitate effective care transitions by providing guidance and support to patients and their families, helping them understand their health conditions and care options.
• Conduct in-person and telephone visits to promote patient self-care management, utilizing coaching tools such as the Personal Health Record.
• Identify and address medication discrepancies, assisting patients in reconciling these with their physician or pharmacist.
• Educate and coach patients to recognize signs and symptoms of worsening conditions and take appropriate actions.
• Encourage patients to attend scheduled appointments with their primary care physician and other necessary healthcare professionals.
• Enter client information and interactions into PeerPlace and other data systems used by the Care Transitions program.
• Provide information about The Span Center and other community resources, referring patients for further advanced care counseling as needed.
• Proactively seek and cultivate additional referral sources to expand the program, while promoting Senior Connections services to physician practices, facilities, and supportive services.
• Actively engages in professional development programs and monthly supervision meetings.
• Attends meetings and training sessions to enhance knowledge and skills.
• Prepares and maintains reports, records, and files using modern computer automation technology.
• Participates in advocacy efforts to support and address the diverse needs of the communities we serve.
• Supports opportunities for community volunteers to engage with relevant aspects of their department or program, with support from Volunteer Services Staff.
• Performs other duties as assigned.