Job Summary: The SNF Discharge Patient Engagement Coordinator will work closely with the Patient Engagement Manager to facilitate the discharge process for short-term skilled nursing facility patients. This role is essential in establishing relationships with patients and their families, ensuring they are informed and prepared for follow-up care after discharge. The coordinator will play a key role in managing care transitions to home care services and providing education to patients about their post-discharge plans.
Key Responsibilities: Assist in developing relationships with patients and families to ensure a smooth transition from the SNF to home care.Coordinate the discharge process, including scheduling follow-up appointments and arranging home health services.Educate patients and families on discharge plans, including medication management and post-discharge care instructions.Collaborate with healthcare teams to gather and communicate necessary patient information for continuity of care.Identify and address any barriers that may affect a patient's discharge or transition to home care.Maintain accurate and up-to-date records of patient interactions and care plans in accordance with facility policies.Participate in team meetings and contribute to continuous improvement initiatives in the discharge planning process.Coordinate with services in marker to assure high quality care for patients. Care coordination for high risk patients at home to prevent hospitalization and optimize care. Qualifications: Bachelor's degree in Nursing, Social Work, or a related field (preferred).Experience in discharge planning or patient education (minimum of 2 years preferred).Strong interpersonal skills with the ability to communicate effectively with patients and families.Ability to interface with social workers and discharge planners in hospitals and SNFs to facilitate referrals and coordinated care.Knowledge of community resources and services for post-discharge care.Excellent organizational skills and attention to detail.Ability to work collaboratively within a multidisciplinary team.