1. Interviews patient and family/caregivers to compile and document relevant information (demographic, economic, social, institutional, etc.).
2. Performs administrative assessment of patient’s transition readiness and eligibility for related programs according to established guidelines.
3. Collaborates with clinical and non- clinical team members to develop a transition of care plan for patient and family/caregivers.
4. Provides sensitive, culturally diverse assistance/guidance to patients, family members and caregivers.
5. Assists with scheduling appointments, transportation, medication orders/refills, ensuring insurance coverage, and related administrative support activities.
6. Describes the advantages of available programs and services, and provides related program information and materials.
7. Serves as a point-of-contact for patient and family/caregivers. Encourages use of related resources to maximize wellness and independence.
8. Participates in team meetings to provide non-clinical input regarding patient status and activities.
9. Follows up with patient/family after transition to monitor overall service delivery and identify and resolve any gaps in service impacting patient care.
10. Maintains integrity of records in accordance with policies, procedures and related regulations.
11. Gathers related metrics and generates reports summarizing transition activities.
12. Performs related duties as required.