Charlottesville, Virginia
Care Transition Coach Job Opening in Charlottesville, Virginia - Since 1975, the Jefferson Area Board for Aging, JABA, has been serving the needs of the aging community in the Thomas Jefferson Planning district (the city of Charlottesville and the counties of Albemarle, Fluvanna, Greene, Louisa and Nelson). Through the years, from our roots as a federally mandated Area Agency on Aging to our current position as one of the most innovative and successful aging organizations, JABA has never lost focus of the needs and desires of the community. Working with state and local government, educational institutions, private citizens of all ages, businesses, and other nonprofit organizations, JABA has consistently risen to the challenge of its mission: to promote, establish and preserve communities for healthy aging that benefit individuals and families of all ages.
POSITION DESCRIPTION
Care Transitions Coach
GENERAL DEFINITION OF WORK
Care Transitions is a program designed to ensure safe and effective transfers across health care settings, serving as a bridge between the professional staff in a care setting (e.g. hospital) and the patient and/or family. The coach provides information, guidance and instruction around an individuals health and health care needs following discharge from a hospital, rehab center or nursing facility. The practice model used is evidence-based, focusing on skill transfer for the patient and/or caregivers self-advocacy. The coach actively listens to patient and/or caregiver in order to assist them with the development of a personal health record, a working understanding of medication management, scheduling of follow-up medical appointments and recognition of symptoms indicating that their condition is worsening. The coach communicates routinely with professional staff across settings, and works collaboratively with all involved with patient well-being, including referring to other JABA programs to meet a person's social or non-medical needs. Outside of the care transitions intervention the coach will be trained on chronic disease self-management, anxiety, depression, fall prevention, and other programs which support independence. The coach documents all pertinent interactions and results in a timely manner, using available required systems. The coach will be in the field a significant portion of their time visiting on average 30 Clients in-home per month, and typically does phone contact with 40 or more clients.
TYPICAL TASKS
Frequently travels to hospitals and homes to assess needs, condition, and support systems of clients.
Performs hospital visits to provide program information, accept patients into coaching program
Schedules home visits and follow-up phone calls to effectively meet with clients.
Serves as a guide to the patient and/ or care giver, coaching in addressing critical issues and self-management tasks.
Works with patient to identify concerns and needs while making referrals within and outside of JABA as appropriate.
Duties performed primarily in office, hospitals and patient homes.
Will manage data entry into electronic record keeping sources.
Works independently as a community resource.
Completes accurate and timely documentation on each patient and client.
KNOWLEDGE, SKILLS AND ABILITIES
Ability to work independently and efficiently in self-structured environment
Excellent verbal and written communication skills
Communicates and works closely with supervisor
Knowledge and appreciation of cultural diversity and low literacy issues in care provision.
Intermediate computer skills and experience
Basic understanding of common issues related to aging
Uses resources to obtain knowledge and information as needed
Demonstrates excellent judgement in a variety of settings where immediate supervision may not be available
Demonstrates ability and willingness to self-motivate, prioritize and change processes to improve
Adapts well to changing patient or organizational priorities
Demonstrates strong ethical practice; represents JABA in positive, professional manner
Demonstrates ability to collaborate and work as a team with other professionals
Following training, demonstrates understanding and use of Care Transitions Model
Demonstrates understanding and use of appropriate confidentiality practices
Effectively engages in self-evaluation of skills and sets appropriate goals for professional development
EDUCATION AND EXPERIENCE
High School Diploma; post high school coursework preferred
Experience in health or human services preferred, but willing to train the right individual
Please submit a cover letter and resume with application.
Job Type: Full-time
Required education:
High school or equivalent
Required experience:
Healthcare Services: 1 year
Required license or certification:
Drivers License
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