Major Responsibilities:

Collaborates with both hospital and/or clinic caregivers as a resource regarding home care 

services and provides general education of services. 

Educates patients/families on home care, palliative care, and hospice services and is available to answer questions allowing patients to make an informed decision regarding their discharge plan for post-acute care. 

Regularly attends the outcome facilitation team meetings on the individual hospital units to provide input regarding services that could be provided in the home. Communicates with social workers or case managers on complex cases. 

Serve as the main communication link between patients, providers, and external partners. 

Initiate the transfer process to the Hospital at Home program, including provider notification and coordination with the care team.  Address any patient and/or caregiver questions and concerns through review of the admission packet.  Obtain formal patient consent to the program after medical clearance provided by provider.  

Coordinate and execute the key steps required for a smooth and timely transfer to Hospital at Home. This includes notifying the care team, documenting acceptance, confirming logistics, and ensuring the patient’s needs—such as medications, oxygen, and equipment—are addressed before departure 

Performs assessment of patient to include skin, cognitive, mobility. 

Applies comprehensive critical thinking to evaluate the patient wholistically. 

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the

ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Minimum Job Requirements 

Education

RN PT, OT or SLP. Nursing experience preferred.

Certification / Registration / License 

Licensed in state the teammate practices – RN, PT, OT or ST License 

Experience

2 years of health care related experience            

Knowledge / Skills / Abilities

Strong understanding of the workflows of Hospital at Home, broad understanding of payors, and able to complete a medical, physical, and cognitive screen of the patient. 

Excellent communication skills. Must be able to speak clearly and hear to communicate with people in person or over the telephone. 

Good organizational, analytical and problem-solving skills.  

Proficiency in clinical skills with the ability to work under direction and make sound judgments. 

Demonstrated ability to educate clinical staff and the community. 

Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. 

Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs. 

Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families. 

Physical Requirements and Working Conditions

Able to lift 50 lbs . 

Preferred Experience 

3 years 

Preferred Knowledge / Skills / Abilities 

Ability to take initiative, strong verbal and interpersonal skills