Registered Nurse - Transition Coor- HF at Home - Detroit

GENERAL SUMMARY:

Works to ensure accurate and appropriate gathering of demographic and clinical patient information prior to discharge from the hospital and start of care. Assesses patient for appropriateness of Henry Ford at Home services, identifying support required regarding the patient's needs. Is responsible for educating, developing and strengthening relationships with referral sources, senior leaders, and Henry Ford at Home providers. Coordinates and assists hospital/facility case managers in ensuring a smooth transition for patients from the inpatient setting and/or physician offices. Provides home infusion visits in patient homes and manage patient caseloads when applicable.

The Hospital at Home requisition needs to reflect that this is an inpatient admission eligibility screening and collaboration role.

• Assessing patients for eligibility based on inpatient admission criteria

• Completing all screening using clinical judgment

• Presenting cases to the Medical Director for approval

• If approved, approaching the ER physician for final acceptance

• Coordinating transportation, inpatient medications, infusions, oxygen, and DME to transition the patient home as quickly as possible so inpatient level care can begin in the home

This role does not include home visits. The Transition Coordinator will focus on program education only and will primarily be stationed in the ER and observation areas. Other TCs already support at home services.