Transitional Care Responsibilities

• Attends discharge planning meetings. Reviews the patient’s medical record and gathers clinical information from the current care delivery team and patient.


• Provides information to patients and caregivers about NLH post acute discharge plans.


• Collaborates with all members of the interdisciplinary team to develop a safe transitional plan to the next level of care. Ensures all clinical and personal transitional goals are met throughout.


• Advocates on behalf of the patient and the healthcare provider for needed patient resources and services.


• Provides written communication to the receiving clinician as the patient transitions from one level of care to the next. Contacts the patient’s PCP with each transition of care, providing a summary of the patient’s clinical status. Collaborates with the PCP to provide direction to enhance the effectiveness of the healthcare delivery team, including transitions across physical settings and to monitor and manage changes in health status.


• Maintains excellent documentation of patient encounter records. Enters specified data elements into electronic dashboard with each patient transition or discharge.


• Develops and maintains plan of care for NLH-based patients.

• Graduate of an accredited School of Nursing


• 3 to 5 years related experience


• Case Management certification from accredited organization strongly preferred