Transition Care Coach Full Time

Vanguard Home Care - Westchester, Illinois

4/19/2017 4:54:32 PM

The Transition Care Coach provides patients and caregivers with the necessary information and support during the transition from the hospital to home. The Transition Care Coach assists them to successfully manage their health care needs following a hospitalization. The Transition Care Coach will follow each patient for 30 days post hospital discharge.

Identify patients at high and moderate risk for readmission.

Run daily readmission reports to identify patients that meet criteria for Transition Care Coach Program.

Meet with the patient bedside and explain role of Transition Care Coach and obtain consent. Begin the coaching relationship.

Teach the patient/client and family/caregiver self-care techniques as appropriate. Provide medication, diet and other instructions. Recognize and utilize opportunities for health counseling with patients and caregivers.

Complete home visits per patient as appropriate.

Provide telephone monitoring for 30 days post discharge from the hospital.

Visit patients in skilled facility as appropriate.

Complete accurate and relevant documentation.

Communicate and collaborate with physician, home health agency, skilled nursing facility and other health care team members as needed.

Advocate for resources on the patient’s behalf as appropriate.

Manage resources (scales, med planners, medication vouchers, journals, etc) appropriately while demonstrating fiscal responsibility.

Attend appropriate meetings/ provide presentations to educate health care team members about the role of the Transition Care Coach.

Participate in webinars, find research/journal articles related to reducing readmissions and integrate current evidence-based research into Transition Care Coach model.

Demonstrate a true commitment to the success of the program. Continually evaluate the Transition Care Coach Program and offer opportunities for improvement.

Performs all other responsibilities as assigned.


1. Graduate of an accredited school of professional nursing.

2. Current licensure as an RN in Illinois.

3. Minimum one to two (2) years general nursing experience, med/surg, or critical care experience. Home health experience strongly preferred.

4. Maintains current CPR certification.

5. Exercises excellent observation and sound nursing judgment, excellent oral and written communication skills.

6. Self-directed and able to work with minimal supervision; and excellent organizational skills.

7. Flexible and cooperative in fulfilling role obligation.

8. Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order.

Job: Nursing

Hospital/Facility: Vanguard Home Care

Job Type: Full-time

Shift Type: Days

Westchester, IL

Westchester, Illinois