Scottsdale, Arizona6 days ago
Supports and coordinates with patient, family and inpatient multi-disciplinary team members providing appropriate post-acute level pathway, screenings, assessments, care coordination, discharge planning, advance directives, early & post-acute interventions, readmission risk, barriers to care outpatient including home support, medication management, expectation, etc., post-acute discharge plan, after-care plan of the assigned evidenced based care management pathway to promote a smooth transition primarily from a hospital discharge to a less acute or outpatient setting. Assures PCP is aware of patient’s admission Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific “red flags” of complications Conduct effective post-hospitalization home visits, telephonic monitoring, or both depending on the risk for readmission.