The Patient Care Coordinator's (PCC) primary responsibility is to act as a patient advocate and to coordinate care both internally and externally. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The PCC will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. They will receive reports of changes in patient condition and ensure the appropriate level of care is provided. The PCC will review new patient referrals and determine level of care required for each patient. This clinical liaison position may assess each potential patient to determine their level of health literacy and be adept at ensuring the individual and their families are included in care planning. They may perform in field quality assurance to support care and promote training. The PCC may visit patients in the hospital to coordinate a smooth transition back home. They will document findings and any training or education provided. The PCC will interact with other community agencies to coordinate services and make family members aware of other appropriate related services.
Responsibilities: Essential Functions
- Facilitates admission to home health services, including insuring the agency can meet the needs of the patient.
- Calls the individual to explain home care orders, services, and agency procedures and checks on customer satisfaction.
- Verifies address, phone number and payer information, ensures eligibility criteria are met, and coordinates with patient's physician to obtain orders and referral information.
- Facilitates referrals to internal and external services to ensure supportive care at home.
- Involves the family-caregivers in the educational process, educational-coaching needs and introduces the individual-family to Homecare journal for LHC Group agencies.
- Collaborates with hospital and rehabilitation facilities regarding patient care being received and discusses potential needs at discharge.
- Ensures availability of primary care physician to follow the plan of care. May assist patient with arrangement of a visiting physician where available and when appropriate.
- Coordinates discharge follow-up appointment with the physician (as applicable), patient and home care provider.
- Receives changes in patient condition and coordinates care with personal care aide, service coordinator, patient, family and physician.
- Acts as a coordinator between any home and community based services, private duty facility, hospital and home health services to facilitate a continuum of quality care for a home based client.
- Reviews new referrals to determine patient's need for services (equipment, visiting physician, HC, HH, PD and ADS).
- Assists the agency in preparation of accepting care of the patient.
- Begins the process of obtaining F2F information.
- Serves as a liaison between the agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency.
- Consults with team members to effectively identify opportunities for quality improvement and ensures that the proper level of service is provided to patient.
- Promotes patient safety and informs appropriate staff of any safety problems in the home promptly and documents appropriately.
- Promptly reports all non-functioning equipment or unsafe conditions to appropriate personnel.
- Provides services in accordance with policies and applicable state, federal, Medicare, Medicaid, HIPAA and other regulations and standards.
- Communicates to case managers or hospital any active patients that transfer from home health into a facility and coordinates resumption of care with patient and case managers or hospitals prior to discharge.
- Provides follow up feedback to referral sources regarding status of admissions and any non-admit decisions.
- Serves on facility committees, if requested, and works with hospital and personal care focus groups to assist in systems integration and process improvements which result in improved patient outcomes and transitions of care.
- Schedules and performs phone follow up calls to patients 48 hrs after admission or resumption of care to ensure needs have been met.
- Collects data on weekly activities and provides updates to Director of Nursing and supervisors as assigned.
- Attends weekly meetings and company provided in-service when required.
- Attends and participates in multidisciplinary patient case conferences, agency meetings as scheduled with staff, DON, Medical Director and Medical Advisory Board.
- Observes patient confidentially at all times.
- Provides education in-services to effectively communicate to whom the features, benefits and specialty programs of LHC Group apply and to educate staff as to what services are available in the home.
- Demonstrates a desire to promote the LHC philosophy, ""It's All About Helping People??"" and seeks ways to facilitate helping more patients.
- Communicates with growth team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service area.
- Meets personal performance goals established by manager and submits weekly their completed number of encounters and coordinating admissions.
- Other duties as assigned withing position''s scope.
Qualifications: Experience Desired
- One year home care experience or one year hospital case management experience preferred.
- Must have vehicle, current driver''s license and appropriate automobile insurance.
- Must be an RN, LPN-LVN with current, active license in good standing in the state of service.
- Skilled in making effective verbal, and written communications with subordinates, co-workers, consumers, referral agencies and conflict resolution skills.
- Ability to educate consumers on all service lines and present to seniors and aides in a group setting
- High energy level and passionate about care delivery
- Must have excellent organizational skills and ability to complete competing priorities
- Must have thorough understanding of home health qualifying criteria and coverage guidelines
- Ability to listen attentively and offer care options based on individual patient health needs
- Proficient computer skills ??- ability to navigate Microsoft email, word, excel, power point and home health agency software system
Our company was founded over 20 years ago on the principle that “it’s all about helping people,” and we live by those words today. It’s our mission to provide exceptional care and unparalleled service to patients and families who have placed their trust in us. We grow to fulfill this mission. When you become part of the LHC Group family, you’re choosing a career path that will challenge you to grow both personally and professionally.
Every day, all across the country, our LHC Group family is helping people. There are 10,000 of us, standing shoulder to shoulder, helping the patients in our care live, fuller, healthier lives. We do this because helping people is, quite simply, the reason we exist. It’s our purpose.