New

RN Transition Coor-Henry Ford at Home

Henry Ford Health System
United States, Michigan, Detroit
May 05, 2025
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. PRINCIPLE DUTIES AND RESPONSIBILITIES Independently participates in the clinical assessment, problem identification, and planning functions for patients who have been identified by the case management team, other health care facility personnel, physicians, or patients/families as possibly needing Henry Ford at Home products and services 2. Uses clinical assessment skills to determine the patient's appropriateness for Henry Ford at Home services by reviewing the patient's medical condition as well as the patient's and caregiver's potential ability to assist with aspects of the care plan, performing an assessment identifying required community services, and communicating the needs with the physician and other appropriate individuals. 3. Collaborates and communicates with Henry Ford at Home leaders and staff to ensure appropriate and timely referrals. Performs patient and family education prior to start of care; provides information and education to patients and families prior to discharge 4. Interprets diagnostic data and incorporates data into the assessment. Assess health problems/perceptions of the client and or family and client's expectations 5. Collaborates with referral sources to identify problems and resolutions 6. Coordinates patient discharge with hospital/facility case managers, including patient and/or family and other members of the health care team 7. Determines appropriate frequency of nursing visits/duration based on patient needs when applicable 8. Reviews and remains updated on knowledge of Henry Ford at Home criteria, 9. Medicare conditions of participation, 3rd party payer information and CHAP guidelines. 10.Acts as a consultant and subject matter expert to the health care facility staff, patients, caregivers and the community for information regarding various aspects of Henry Ford at Home products and services. CERTIFICATIONS/LICENSURES REQUIRED * Registered Nurse in the State of Michigan Additional Information Organization: Community Care Services Department: HHC Intake Shift: Day Job Union Code: Not Applicable