Post-Acute Care is an end-to-end post-acute offering that manages up to 90-day episodes of care, beginning prior to the patient’s discharge from the hospital, or for elective surgical cases, outreach begins prior to hospitalization. The program optimizes our home-based network, identifies the likely best site-of-care for the patient, manages length of stay (LOS) if a Skilled Nursing Facility (SNF) is appropriate, and reduces hospital readmissions. Our program also coordinates all of the services required for a patient to transition to their home faster and safer, via our network of home health, durable medical equipment and home infusion providers, all of whom are supported by our Post-Acute Care coordination team.
This position utilizes clinical expertise to manage assigned Post-Acute Care patients’ transition from acute care setting to the home setting through telephonic outreach to provide teaching methods, combined with facilitating in home health care services to accomplish the goals of the Post-Acute Care Program. Position initiates outbound calls to Post-Acute Care patients, hospitals, discharge planners, physicians, and home health agency nurses providing education regarding the benefits of Post-Acute Care. Engages Post-Acute Care patients in the program and administers initial assessments, progress surveys and discharge surveys. Position works closely with the Post-Acute Care patient home health agency nurse to facilitate education and adherence to establish health care goals and care plan. Participates in performance and operational improvement activities. Works under moderate supervision.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.