Job Objective: The Transition Care Coordinator (TCC) is a vital resource responsible for managing both the physical discharge of patients and their preparation for a successful transition from hospital to home or other care settings. The TCC ensures that all discharge processes are completed accurately and efficiently, including verifying orders, resolving logistical challenges, and coordinating with the interdisciplinary team. This role also provides tailored education to patients and families on discharge instructions, medications, follow-up care, and community resources. By addressing barriers such as incomplete orders, medication access, or transportation delays, the TCC ensures timely and safe discharges while empowering patients and families with the knowledge and resources needed to manage their health post-discharge. The TCC operates independently, demonstrating initiative and adaptability in dynamic healthcare environments, improving patient outcomes, reducing readmissions, and enhancing satisfaction.

Duties and Responsibilities:

1. Patient Discharge Execution

1. Physically discharge patients by verifying that all orders are completed and ensuring the readiness of discharge medications and documentation.
2. Collaborate with the bedside RN and Charge Nurse to help eliminate any identified barriers to a timely discharge.
3. Coordinate with case managers, pharmacists, and nursing staff to address any last-minute issues or barriers to discharge.
4. Help resolve logistical challenges, such as arranging transportation or ensuring proper equipment is available for home use.
5. Oversee the timely execution of all discharge-related tasks to meet hospital benchmarks for efficiency.

1. Patient and Family Education

1. Provide detailed discharge education to patients and families, ensuring they understand instructions, medications, and follow-up care.
2. Develop and deliver educational materials tailored to patients' literacy levels and cultural needs.
3. Proactively identify patients with upcoming discharges to initiate early education, reducing last-minute confusion or delays.
4. Conduct teaching sessions to address patient or family questions and concerns before discharge.

1. Collaboration and Communication

1. Serve as the primary liaison between patients, families, and the interdisciplinary care team during the discharge process.
2. Communicate effectively with all team members to ensure a seamless transition of care, resolving any discrepancies in orders or processes.
3. Ensure alignment between discharge plans and patient-specific needs, coordinating additional services as required.

1. Process Optimization and Documentation

1. Maintain accurate and timely documentation of discharge processes and patient education in the electronic health record (EHR).
2. Analyze discharge-related data, such as length-of-stay metrics and readmission rates, to identify and address gaps in workflow or patient preparation.
3. Propose and implement improvements to streamline discharge operations and enhance the patient experience.

1. Quality and Safety

1. Ensure compliance with hospital policies, accreditation standards, and evidence-based practices related to discharge and education.
2. Address potential safety risks, such as medication errors or inadequate follow-up care plans, before discharge.
3. Monitor and report trends in patient outcomes related to the discharge process and contribute to quality improvement initiatives.

1. Patient and Family Advocacy

1. Advocate for patient understanding and readiness by addressing barriers such as language, literacy, or access to resources.
2. Work with social workers and community organizations to connect patients to external support systems.

Non-Essential Duties:

• Participate in hospital-wide educational initiatives related to patient discharge.
• Assist in training staff on effective patient education strategies.

Knowledge, Skills and Abilities:

Knowledge

• Best practices in patient education and health literacy.
• Hospital discharge protocols and follow-up care needs.
• Principles of adult learning and communication.

Skills

• Exceptional communication and interpersonal skills to engage patients and families.
• Strong organizational skills to manage multiple patients and educational initiatives.
• Proficiency in electronic health record systems for documentation.

Abilities

• Effectively teach and adapt content to meet diverse learning needs.
• Work independently while coordinating with interdisciplinary teams.
• Assess and respond to patient and family concerns with empathy and professionalism.

AVMC Values: All AVMC employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone.  Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.

Education and Experience:

Education

• Bachelor of Science in Nursing (BSN) required.

Experience

• Minimum of 3 years of clinical nursing experience, preferably in discharge education or patient care coordination.
• Experience working with diverse populations and health literacy challenges is highly preferred.

Required Licensure and/or Certifications:

• Active Registered Nurse (RN) license in California.
• Certification in Patient Education (preferred).

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Attendance and Punctuality Policy.
• Ability to adhere with AVMC Leaves of Absence Policy.
• Ability to adhere with AVMC Paid Time Off (PTO) Policy.
• Ability to adhere to the department dress code.
• Ability to organize work and establish priorities.
• Ability to expand on own initiative in performance of duties.
• Skill and ability to follow the telephone etiquette/standards.
• Ability to function effectively under pressure and meet time parameters.
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
• Ability to maintain the confidentiality of patient, hospital and department information.
• Ability to adhere to safety rules and regulations.
• Safely and effectively uses all equipment necessary to carry out duties.
• Ability to interpret and function under hospital and department policies and procedures.
• Conforms with required and appropriate accreditation and regulatory requirements.
• Conforms with and supports hospital quality assurance and improvement guidelines.
• Ability to participate effectively in department and hospital staff education.
• Display a willingness to work as a team player.
• Ability to give and support the highest level of patient/customer satisfaction at all times.
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the Code of Conduct.

Physical Requirements and Working Conditions:

• A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB.  THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.