Acute Care Transitions Coach

The Care Transitions Coach conducts comprehensive assessments, promotes self-management and delivers evidence-based coaching using the Four Pillars of Care: Medication Management, Follow Up Care, Disease management education , and Personal Health Record utilization. The clinician performs medication reconciliation, develops person centered care goals, coordinates HCBS and LTSS needs, and collaborates with providers and interdisciplinary teams to reduce avoidable readmission. Responsibilities include empowering members through education, motivational interviewing, ensuring timely follow up care, addressing social and environmental barriers, and documenting all interventions, as our goal is to prevent avoidable readmissions.

Primary Duties

1. Care Transitions & Member Engagement:

Evaluate members for the DHAD/Medical Mutual of Ohio Transitional Care Program, using criteria that identify individuals at highest risk for readmission, functional decline, or medication mismanagement, to improve safety for persons with complex care needs.

2. Transitional Support and Evidence‑Based Coaching:

Typical workload is 18-22 weekly coaching interventions with members in the community-based setting. This role may vary in visit delivery—interventions can be delivered with either in‑home or telephonic coaching, and reinforces the Four Pillars Care during all interactions:

- Medication Management: Conduct medication reconciliation, identify discrepancies, and support safe medication routines.

- Follow‑Up Care: Ensure timely PCP and specialist follow‑up; coach members to schedule and prepare for appointments.

- Red Flags: Teach members to recognize early warning signs of worsening conditions and appropriate response actions.

- Personal Health Record (PHR): Promote member ownership of the PHR as a communication and self‑management tool.

3. Program Orientation-Empowerment Focused:

Educate members and caregivers on the purpose of transitions coaching, clarifying that the coach is not replacing providers but empowering the member to own their health, consistent with the Dr. Eric Coleman coaching philosophy.

4. Patient‑Centered Care Planning: Use transitional care frameworks to identify needs across medical, behavioral, cognitive, social, and HCBS domains. Allowing members to steer the conversation and identify priorities.

5. Health Education, Self‑Management & Referrals:

Provide education that supports empowerment and self‑management rather than dependency. Use motivational interviewing and reflective listening to help members understand their conditions and identify appropriate community resources.

6. Outcome Evaluation:

Monitor progress toward goals, therapeutic response, and safety indicators (falls risk, caregiver stress, red flags). Document outcomes that demonstrate improved functional status and reduced high‑cost utilization, consistent with evidence base reduction in readmissions.

7. Medication Reconciliation:

Conduct medication reconciliation using patient‑led review (Show me what you're taking) to uncover discrepancies, expired medications, and barriers to adherence.

8. LTSS Integration:

Perform comprehensive HCBS assessments that incorporate LTSS needs, environmental factors, and social determinants of health to address LTSS gaps in transitions care.

9. Risk‑Responsive assessments:

Complete assessments triggered by major health or functional changes, ensuring updated medication reconciliation, red flag education, follow up care and personal health records (PHR), to promote member ownership of the PHR as a communication and self‑management tool.

10. Data‑Informed Evaluation:

Use member input, provider records, claims, and care team feedback to create a holistic picture of risks and need for understanding the patients experience and barriers to safe transition.

11. Acuity & Service Needs Analysis:

Analyze assessment data such as health information exchange platforms, Clinisync and discharge instructions to prevent avoidable readmission, improve safety, and support self management.

12. Collaborative Care Planning:

Coordinate with MMO care managers, providers, caregivers, and interdisciplinary teams to ensure care needs reflect the Four Pillars and member‑identified goals.

13. Comprehensive Treatment Planning:

Complete falls risk assessment and social determinant of health screenings, focusing on empowering members to manage their conditions and prevent readmissions.

14. Plan of Care:

Focus on empowering members to manage their conditions and prevent readmissions. Supporting safety, independence, and functional improvement, key outcomes of effective transitions coaching.

15. Plan Updates:

Reinforce the Four Pillars of Care during all interactions, ensuring continued alignment with member goals.

16. Documentation Compliance:

Complete all required documentation within specified timeframes and in accordance with organizational procedures.

17. Training & Education:

Fulfill all mandatory training requirements as outlined by the organization and its partners.

18. Clinical Judgment:

Apply clinical expertise to guide decision‑making, ensuring safety, accuracy, to improve quality and reduce harm.

19. Technology Utilization:

Utilize approved IT systems and protocols in accordance with contractual, regulatory, and organizational standards, while promoting and reinforcing member engagement with their personal health record. Demonstrate proficiency in Microsoft Teams, Excel, and documentation platforms to support both in‑person and telephonic visit workflows. Visits may be prescheduled or require independent scheduling, and the role requires comfort navigating both formats with accuracy and professionalism

Qualifications

Required:

- One year of experience in home health care or geriatrics is required.

- Registered Nurse in the State of Ohio is required.

Preferred:

- Strong written and verbal communication skills and organizational skills.

Ability to engage and empower members and caregivers in the pursuit of health and wellness.