Post-Acute Health Coach

Reporting to: PHSO Acute and Post-Acute Care Manager

Supervisory Responsibility: N/A

FLSA Status: Non-Exempt, Hourly

Department: MercyOne System Office, Care Management

Effective Date: 01/28/2021

Mission Statement: MercyOne serves with fidelity to the Gospel as a compassionate healing ministry of Jesus Christ to transform the health of our communities.

MercyOne Vision Statement:

MercyOne will set the standard for a personalized and radically convenient system of health services.

MercyOne Cultural Beliefs:

Be ONE

I benefit from and strengthen MercyOne.

Personalize Care

Your experience. My responsibility.

Own It!

I own my actions to deliver our key results.

Improve Daily

I make improvements every day for those we serve including each other.

Innovate

I imagine and embrace bold new ideas to revolutionize health.

Job Summary: The RN Post-Acute Health Coach provides care management and care coordination services to Population Health patients receiving services at a post-acute care facility delivering standardized oversight of progress, length of stay, and continuity of the plan of care for patients in post-acute facilities. RN Post-Acute Health Coaches bridge the communicate gap between the care team and the patient/family, the hospital and facility, and the facility and the PCP/Health Coach. Advocate for a diagnosis specific goal length of stay without sacrificing quality and measure expected versus actual length of stay. This position promotes and monitors utilization of MercyOne wrap around services; and works to prevent avoidable ED visits and hospitalizations.

Essential Position Expectations:

1. Provides care management and care coordination services for Population Health patients receiving services in a swing bed, Skilled Nursing Facility, Inpatient Rehab Facility, or Long-Term Acute Care Hospital.

2. Determines the goal Length of Stay based on primary diagnosis for skilled need and communicates the goal to the post-acute care facility contact.

3. Communicates with care team and/or patient twice per week.

4. Attends facilitys weekly multi-disciplinary meeting in person/via phone/virtually or request an update if unable to due to conflicts.

5. Attends or initiates Patient Care Conferences as needed.

6. Routinely conducts PHSOs standard Functional Assessment Survey to document functional status and progress towards goals.

7. Actively coordinates discharge planning with care team, providers and patients encouraging utilization of MercyOne wrap-around services. Monitors progress towards discharge and works proactively to overcome identified. barriers/concerns for discharge.

8. Applies motivational interviewing to strengthen the patients own motivation for change and movement towards health behavior goals.

9. Round on patients and provide coaching and education to support self-management.

10. Facilitates warm hand-off transition to Primary Care Provider and PHSO RN Transition Health Coach by providing medication list, discharge summary, and any appropriate additional items.

11. Participates in quality improvement, measurement and data collection to include populations with clinical and financial risk.

12. Delegates to support team such as community health workers, as appropriate.

13. Informs primary care provider of ongoing care management activities, patient progress and changes in the patients health status.

14. Documents all patient interactions in the patients health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.

15. Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience.

16. Upholds and supports PHSO standard workflows and procedures at accreditation level quality.

Knowledge & Skills:

1. Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.

2. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.

3. Demonstrated capacity to problem solve and prioritize in complex situations.

4. Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist.

5. Strong self-motivation and ability to work independently without direct supervision or support.

6. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.

7. Ability to function effectively in a team based environment.

8. Basic Excel and Word skills.

9. Ability to understand and apply guidelines, policies and procedures.

10. Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.

11. Proof of completion of Mandatory Reporter within three months of hire.

Mental & Physical Demands:

1. Must be able to pass a pre-employment drug screening test at time of hire.

2. Work with regular and predictable attendance.

3. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting.

4. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitor and written materials. Occasionally required to detect unusual odors that could indicate environmental issues.

5. Use of usual and customary equipment used to perform essential functions of the position.

Education: Graduate from an accredited school of nursing. BSN preferred.

Experience: Minimum of 5 years previous nursing experience or 3 years and BSN in lieu of experience. Varied clinical experience preferred.

Certifications & Licenses: Iowa state licensure as a Registered Nurse

The above is intended to describe the general content of and requirements for this job. It is not intended to be a complete statement of duties, responsibilities or requirements.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.