Transitions Coach

Job Brief: Transitions Coach (RN) The Transitions Coach is responsible for coordinating care for identified members with complex medical conditions in collaboration with hospital physicians, IQM/QRM staff (IPCC, ICM, CM, SW), practitioners, and other providers. The goal is to support and facilitate a smooth transition from the acute care setting to alternative levels of care or services, improve self-management skills, promote post hospital discharge follow-up, and maintain member safely in the community by optimizing health outcomes across the continuum.

The activities include attending inpatient case management rounds, face-to-face assessment of identified high risk members, and development of a collaborative plan with the member for discharge and follow-up to ensure continuity of care. The Transitions Coach will identify and communicate any barriers to discharge plan implementation and will monitor and evaluate the efficiency and effectiveness of services and resources provided to members for up to 30 days post-discharge from acute care setting.

The role of the Transitions Coach is to promote more effective care transitions for members through improved self-management skills, and enhanced patient-provider communication. Model and facilitate new behaviors, skill transfer and communication strategies for patients and families to build confidence that they can successfully respond to common problems that arise during care transitions.

Summary: The Southeast Permanente Medical Group (TSPMG) is one of Georgia’s largest independent, physician-owned, multi-specialty medical groups. More than 700 physicians and 300 associate practitioners work together in a unique integrated care model to provide high-quality care to Kaiser Permanente members. Our focus is on long-term health, effective prevention, diagnosis and treatment of disease .

Care is delivered across 40+ specialties at 26 medical offices featuring state-of-the-art equipment, labs, imaging services, and pharmacies. We also provide surgical services and around-the-clock care at some of the area’s top hospitals. We invite applications for a Transitions Coach to join our practice. About the area: Atlanta, our home for more than 40 years, is a thriving metropolis that blends southern charm with modern art, music, and culture….

w here Southern charm meets big-city energy. From its iconic skyline and rich civil rights history to a buzzing food scene and world-class arts, Atlanta is a city that never stops moving. Home to Fortune 500 companies, a booming tech and film industry, and a strong academic presence, Atlanta offers exceptional professional opportunities.

With a major international airport and a culture that values balance, Atlanta is a smart move for professionals ready to grow and thrive. What You Can Expect:

1. Conducts timely review of all referrals to the Transition Coach Program within designated timeframe per policy and procedure and evaluates priority for Activation Assessment.
2. Performs a thorough and objective face-to-face assessment of the member including physical, psychosocial, environmental, financial, and health status expectation through the use of hospital records, contact with the member/family or significant others.
3. Develops an individual, mutually established plan of care, based on the activation assessment results and member goals, in conjunction with the KP Hospitalists and other practitioners that identifies specific goals to be accomplished within 30 days post discharge.
4. Proactively implements the mutually agreed upon post discharge plan and specific interventions that will lead to the accomplishment of goals as defined. May entail implementation prior to member discharge.
5. Completes home visit or telephonic outreach to identified members within 72 hours post hospital discharge and completes assessment/re-assessment of member status.
6. Communicates plan to the Primary and/or Specialty Care providers, including follow-up appointment.
7. Minimum weekly follow up to routinely assess the member’s status, activities/services, and progress toward the established goals, identify breakdowns in plan, and makes adjustments to the plan, as necessary.
8. Makes referral to other KP programs for continued care if established outcomes are not met within the designated timeframe of 30 days post discharge. These programs include but are not limited to complex and disease specific case/care management programs, Palliative Care, etc.
9. Document all coaching interactions and interventions in Health Connect according to established guidelines.
10. Re-assess and reinforce member’s self-management skills, including symptom and medication management.
11. Arranges, coordinates, and facilitates appointments for the member as needed.
12. Identifies the need for discharge from the Transition Coach Program based on defined goals and criteria.
13. Discharges the member after notifying the member and practitioner as well as any other involved resources such as the PCP, Clinical Pharmacist, Social Worker, etc. Minimum Requirements: Unrestricted current RN licensure in the state of Georgia required or documentation to show intent to seek license. B.S. in Nursing strongly preferred Case Management Certification Care Coordination and Transition Management Course Completion/Certification. Valid Georgia Driver’s license. Three (3) years of clinical nursing experience in a medical/surgical area. At least two (2) years of experience in case management. TSPMG Administrative Staff:

• Are committed to supporting our practice of providing care of the highest quality
• Provide excellence in s ervice
• Are honest and ethical and show Integrity in their a ctions
• Demonstrate accountability for their p erformance
• Dedicated to the success of the Team We Provide You:
• Competitive compensation which considers an applicant’s skills and qualifications, certain degrees and certifications, training, market data, and other relevant factors
• Comprehensive benefits including medical and dental insurance, a pension plan and 401(k), life insurance, short- and long-term disability
• Generous paid time off
• Many additional benefits that support your work/life balance TSPMG is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, veteran or disability status. We maintain a drug and nicotine free workplace and perform pre-employment substance abuse testing and background checks.