AHN Home Recovery Care brings all the essential elements of inpatient care to the comfort and convenience of a patient’s home. The model enables AHN to deliver high-quality, safe and affordable care to patients with non-life-threatening conditions. At AHN Home Recovery Care, you will have the opportunity to make a direct impact on the lives of patients and be at the forefront of shaping a pioneering space in the health care industry. Contessa Health, AHN’s partner in providing Home Recovery Care, is the nation’s leader in redefining the way that patients receive inpatient care in their homes.
As a Recovery Care Coordinator (RCC), you will be at the forefront of this highly innovative care model that allows patients who are clinically appropriate to have the option to receive acute care in the comfort of their own homes in lieu of an inpatient setting. As a Recovery Care Coordinator, you will be fully integrated into the clinical teams at AHN working directly with patients in the admission process and then virtually when patients are at home. In this exciting role, you will work with a variety of AHN teams, including hospitalists, home care and primary care
This role offers the unique opportunity to work directly with the patient and their providers for a full 30 days. This allows you, the RCC, to not only coordinate their recovery from the acute illness but also develop the deep relationships with patients needed to successfully engage them with the resources they’ll need to improve their health and quality of life.
As a Recovery Care Coordinator, you will leverage Contessa’s proprietary workflow platform, advanced telehealth technology, and our interdisciplinary network of doctors, nurses, social workers, and ancillary providers to improve the health and well-being of patients and ease the burden on caretakers.
- Identifies potential patients for program inclusion through rapid recognition of clinical determinants that indicate patient eligibility.
- Possesses clinical knowledge, experience, and acumen to identify, present, and discuss potential HRC patients to providers for program inclusion. These direct discussions usually include ED providers and hospitalists but may span across multiple subspecialties.
- Facilitates communication and coordination between all members of the care team to coordinate admissions.
- Coordinates referrals and appropriate resources to assist patient and/or caregiver in continuation of care in the outpatient setting.
- Initiate the “start of care” process with the patient both in the hospital setting and in the patient’s home by conducting a complete skilled nursing assessment, psychosocial assessment, home environment evaluation, and patient onboarding activities.
- Generates operational quality reports and presents updates on to our partners’ physicians and nurses.
- Maintains all required documentation in all interactions with our health systems’ patients and the care team.
- Follows clinical and operational workflows.
- Provides prompt, courteous, and excellent service to internal and external customers.
- Interacts with the patient and the multidisciplinary team to coordinate the services ordered by our partners’ physicians. Communicates to the appropriate providers about any barriers to the patients’ fulfillment of our partner provider’s Care Plan.
- Communicates discharge information to other clinical departments or members of the Care Team.
- Watches for trends and hurdles involved in health care system and incorporates operational solutions for system challenges, including patient, family and physician responses into an evolving process and model that increases quality and satisfaction– patient or physician.
- Builds and maintains collaborative professional working relationships with physicians, Medical Directors, clinicians, and community at large to develop and implement a successful cross-continuum care management process
- Works with partner physicians to educate patients on the Home Recovery Care model; provides education regarding use of the telehealth system and processes.
- Confirm admission health and home assessment data collection accuracy to ensure the home environment is safe.
- Ensures that patients have access to appropriate services to meet their provider-directed care plan needs.
- Monitors the care that the patient receives and brings it to the attention of a provider.
- Assists as needed in recruiting, client and community outreach and critical incident/incident/complaint management.