The goal of the UMMC Transitional Care Program is to assist recently discharged patients with successfully transitioning from UMMC back to their home. The program is designed to assure open, accurate communication and collaboration between the patient and all involved health care providers.
Benefits of Transitional care:
• Allows patients to better understand and follow discharge instructions
• Helps patients obtain a better understanding of their medications and how to manage them
• Assists patients in communicating with their primary care providers about concerns or changes in condition
• Prevents avoidable hospital readmissions
This program is designed to target vulnerable patients who are at a high-risk for negative post-hospital outcomes.
UMMC is currently seeking a Program Assistant (must have Pharmacy registration and 2 yrs experience) to join the Transitional Care Team.
Under direct supervision assists with identifying community resources for patients that are part of the Transitional Care Coordination Program. The transitional care coordination program identifies patients at high risk for readmission to the hospital. In collaboration with the clinical team, this role is accountable for the continuity and integration of patient care services.
Principal Responsibilities and Tasks
1.Provides assistance to Transitional Care Coordination team to provide patient access to medications before discharge.
- Identifies patient’s prescription benefits.
- Obtains pharmacy benefit information.
- Requests prescriptions for patients from health care providers.
- Obtain prescriptions from UMMC pharmacy to delivers prescriptions to patient.
2. Provides timely retrieval and updates of new patient referrals to the Transitional Care Coordination program.
- Electronically retrieves new patient referrals through system report or pager communication. Disseminates referral to the clinical team. Discusses patient referrals to determine if patient meets acceptance criteria with the clinical team.
- Communicates the status of the patient referral to referral source in a timely manner.
- Documents referral status within the Electronic Medical Record.
3. Identifies internal and external community resources such as housing, transportation, pharmacy assistance program and makes referrals in collaboration with the clinical team. Assists with maintenance of electronic list of internal and external community resources to assist patient with continuum of care.
4. Provides transport tokens or vouchers, documents administrative details on the transportation log.
5. Documents all patient interactions, both telephone and in-person in the appropriate ElectronicMedical Record, regarding continuum of care.
6.Ensures continuity of care with Primary Care Providers and Specialists.
- Schedules patients for appointments with health care providers.
- Reminds patients of pending appointments and contacts them to enquire into reasons for missed appointments.
- Attends appointments with the patient’s health care provider if Care Coordinator or Clinical Social Worker are unable to attend the patient’s appointment with a health care provider.
7.Orders and maintains office supplies and equipment and maintains related expense records.
8. Assists with the review of patients chart to ensure all necessary information has been documented in the patient chart.
9. Schedules and coordinates teams meetings, appointments, travel arrangements and conferences. Assists with preparing agendas, assembles background materials. Attends meetings, prepares notes and performs required administrative follow-up.