What does a care transitions coordinator do?

Caring for communities

After a hospital stay, nearly 1 in 5 Medicare patients are readmitted within 30 days of their discharge, according to the Centers for Disease Control and Prevention (CDC). At Enhabit Home Health & Hospice, we employ a team of care transitions coordinators to help mitigate the risks associated with transitioning home, avoiding costly and inconvenient hospital readmissions.

What is a care transitions coordinator?

At Enhabit, care transitions coordinators work within the Care Transitions Program. The goal of the Care Transitions Program is to complement a patient’s hospital discharge plans and reduce hospital readmissions, providing a safe and effective transition from one care setting to another.

Care transitions coordinators are a resource to patients. They are available to meet with providers, patients and caregivers to help mitigate any risk related to transitioning home.

What does a care transitions coordinator do?

Care transitions coordinators are introduced to a patient’s care journey before they begin home health services.

Their main goal is to prepare patients to go home from either a rehabilitation facility or the hospital. After that, they conduct follow-up calls to answer any questions and ensure the care transition was smooth and successful.

“Typically, I will call the patient 24-48 hours after discharge to touch base with them,” Senior Care Transitions Coordinator Kelly said. “They just get so overwhelmed with the information at discharge that typically more questions or issues arise once home. This call gives us a chance to review, discuss and mitigate any concerns that may lead to a rehospitalization or potential threats to a successful transition home.” 

Other specific care transitions coordinator duties include:
  • Assist patients in the process of navigating post-acute care
  • Assess, plan, implement, coordinate, monitor and evaluate options and services with a primary goal of providing a safe transition from acute care to home for home health or hospice services
  • Integrate evidence-based clinical guidelines, preventative guidelines and protocols in the development of patient-centered transition plans, promoting quality and efficiency in the delivery of post-acute care
  • Promote adherence to post-acute plans and ensure ordered services are completed
  • Represent Enhabit in transitional care activities and strategic relationships with health systems, hospitals, inpatient facilities and physician groups
  • Monitor execution of transitional care services through ongoing quality assurance visits with referral sources
  • Meet and exceed referral and admission goals
  • Act as a clinical liaison responsible for Care Transitions Program admission activity for the territory, while positively impacting patient outcomes and referral source satisfaction

What is it like to be a care transitions coordinator?

Care transitions coordinators play a unique and important part in patient care journeys, especially when helping patients feel better about leaving the hospital. According to Kelly, patients have a lot of anxiety about going home. She enjoys getting to clear the air and help them feel more comfortable about the next steps.

“When patients are in a rehab facility or hospital, they typically have a lot of anxiety about going home or have limited insight of how difficult the process may actually be,” she said. “So, in both scenarios, I spend a lot of time with the patients and family members trying to educate on not only the importance but also the purpose and goals of continued medical support at home.”

When patients experience a smooth transition home, they are less likely to return to the hospital. This allows them to continue receiving the high-quality care they deserve from the comfort of wherever they call home.

“The care transitions role really makes a difference in the transition home,” Kelly said. “The more prepared and involved the patient and family are, the smoother and more successful the transition home is.”

Care transitions patient testimonial

“We had a patient a few years ago whose wife was protective and resistant to home health because she had a bad experience with a different company,” Kelly said as she reminisced about one of her favorite success stories in her career. “However, the patient really needed extra support from the home health team or else we all knew he would just end up back in the hospital again.”

“After establishing a relationship and explaining that Enhabit had a different method of providing care, the wife finally agreed to give us a chance,” Kelly said. “And the patient is still on service with us today. To his wife, we are now the expectation and standard of home health care. The clinicians provided the high-quality care that they do best, and she was a fan.”

Experiences like these – and the process of establishing relationships with patients and their loved ones – are Kelly’s favorite parts about working as a care transitions coordinator.

“Working at the bedside with the patients is the best,” she said. “I love establishing relationships and becoming an active, supportive part in their health recovery journey. It is rewarding to educate patients about home health, talk with them about what’s going to happen, reduce their anxiety and just make a difference when they’re worried about what it’s going to be like when they get home.”

How do I start my career in home health?

Kelly is a firm believer that all patients deserve the opportunity to receive care at home. She’s proud to work for a company that allows people to do just that.

“As a clinician, it’s easy to understand the concerns about a patient’s safety when they transition home,” she said. “You may worry about whether they will be able to function without the high-level support of an inpatient setting. But every person deserves the opportunity to try to go back home – and my job as a care transitions coordinator is to help put the pieces in place to make that happen. I believe we are vital in trying to make that possible for them. Home health is the first, and sometimes the only, line of support.”

Kelly says it’s also crucial to understand the importance of home health and how it can make a difference in a patient’s life before beginning your home health career. But once you take the time to learn and draw connections from previous clinical environments, you are in for a fulfilling job.

“A care transitions coordinator is a very natural role for clinicians,” she said. “Because you do connect the acute care and home health environment. Your clinical background, ability to multitask, experience with patient care in the hospital or home and having the knowledge base for community resources all are vital skills in helping patients transition their care – and you do help bridge the gap for patients. It’s a very rewarding role and I love it.”

At Enhabit, care transitions coordinators are registered nurses, licensed vocational nurses or physical or occupational therapists with 2-3 years of field experience. They also have a strong understanding of customer and market dynamics, as well as transitional care best practices.

To learn more about home health career opportunities at Enhabit, search our open career opportunities near you or sign up for job alerts by texting “CARE” to 98199.