Care Transition Coordinator- Home Health

Company Overview

The Care Transition Coordinators primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post acute care needs. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The CTC will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs the CTC will begin best practice intervention and education to improve patient outcomes and promote patient self management. The CTC will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home. Mederi Caretenders, a part of LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home. Hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home. More hospitals, physicians and families choose LHC Group, because we are united by a single, shared purpose: It's all about helping people. 
Essential Functions

  • Following Right of Choice, evaluates patient and orders for appropriateness for home care
  • Initiates face-to-face patient transition to identify homecare needs, and educate the patient on LHC agency and also verify patient meets Homebound criteria
  • Verifies patient demographic information is correct
  • Presents agency Executive Director with clinical assessment and identification of patient needs to obtain branch approval and acceptance
  • On acceptance, CTC will coordinate organization of transfer orders, educate patient on home care orders and home care services
  • CTC will initiate and complete CTC encounter documentation in Home Care Home Base after branch acceptance to ensure all patient needs are documented and met by the agency
  • Involves the family|caregivers in the educational process, assesses post-discharge educational|coaching needs, and introduces patient|family to Homecare journal for LHC Group
  • Identifies primary care physician to follow the plan of care
  • Educates patient on importance the post facility discharge follow up appointment with the physician
  • Assess patient’s risk for readmission using LACE tool and documents in CTC encounter
  • Educates patient on Homebound criteria and verifies patient meets these requirement
  • Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information
  • Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient’s understanding of medication, pharmacy, and delivery method
  • Coordinates other ancillary services for the patient (DME|Infusion) as needed
  • Assists the LHC Group agency in preparation of accepting care of the patient post discharge
  • Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency.
  • Communicates to discharge planning any active patients that transfer from home health into a Facility and coordinates resumption of care with patient prior to discharge if applicable orders are obtained
  • Provides follow up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency
  • Serves on facility committees, if requested, and works with hospital focus groups to assist in systems integration and process improvements which result in improved patient outcomes and transitions of care as approved by CTC Director
  • Participates in monthly Executive Director and Account Executive meetings to assist with clinical program needs
  • Attends all CTC Department calls and company provided in-services
  • Observes patient confidentiality at all times
  • Provides education in-services to effectively communicate the features, benefits, and specialty programs of LHC Group and to educate referral sources as to what services are available in the home
  • Demonstrates a desire to promote the LHC philosophy, "It’s All about Helping People" and seeks ways to facilitate helping more patients
  • Communicates with growth team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service areas.
  • Meets personal performance goals established by manager
  • CTC will document Start of Care transition CTC encounter note within 24hrs of patient referral/ agency acceptance and update as status of patient transfer changes
  • CTC will document Resumption of Care note if applicable
  • CMCN to be obtained within first year of employment
  • All other duties as assigned


Education & Experience

Experience Requirements
  • Must have one year home health experience or one year of hospital case management experience.
License Requirements
  • Must have current RN or LPN or SW licensure in state of practice
  • Reliable means of transportation and must have current driver's license and auto insurance
Skill Requirements
  • Must have excellent verbal and written communication skills with all members of the healthcare team
  • Must have excellent organizational skills and ability to complete competing priorities
  • Must have thorough understanding of home health qualifying criteria and coverage guidelines
  • Proficient computer skills.


LHC Group
Salary Range
$32,000.00 - 53,000.00
per Year
Salary range estimated by
Orlando, FL 32885, US