- Transitional Care Management (TCM): Focused on outreach during the 30 days after discharge with the goal of reducing ER visits, hospitalizations, readmissions, and post-acute stays
- Reviews daily ADT feeds and initiates contact with patients within 2 days of discharge
- Schedule follow-up for TCM visit with the PCP within 7 days of discharge
- Complete weekly outreach for 30-day post-discharge
- Review discharge plan and ensures services (e.g. Physical Therapy, Home Health) are in place; provides community resources for SDOH (Social Determinants of Health) needs
- Provides patient/ family education regarding health conditions and disease self-management
- Completes medication reconciliation and monitors adherence
- Documents all telephone/ video interactions in EHR patient chart
- Identifies patterns and episodes of care that are predictive of future needs and services
- Coordinates care with other providers involved in the patient’s care as needed
- Triage: Respond to patient telephone calls, refill requests, and electronic health messages
- Demonstrates critical thinking skills and expert nursing judgement to provide appropriate recommendations for care utilizing an approved evidence-based telephone nursing triage protocol
- Works with the RN scope of practice and standing orders to provide prescription refills, medication titration, and home treatments
- Educates patient regarding test results and medical conditions, and explains medical terms and procedures
- Maintains a professional demeanor and focus on patient-centered care
Communication SkillsEHR