RN-Transition of Care

About Legacy Community Health

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information. 

Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to 50 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.

Job Description

Transition of Care Registered Nurses (TOCRNs) are responsible for the telephonic outreach to patients who have discharged from an inpatient setting such as, acute, behavioral health (BH), Inpatient Rehab (IRF), Skilled Nursing Facility (SNF) or Long-Term Acute Care (LTAC) within one (1) business day of receiving notification of the discharge.

Through the thorough assessment of the patient’s physical, mental, and social status, the TOCRN will coordinate with the Care Team to mitigate any risks/barriers that may lead to rehospitalization. The TOCRN is also responsible for facilitating a follow up visit with the assigned Primary Care Team or Behavior Health Provider, to occur within 7 days of discharge.

Essential Functions

• Performs telephonic outreach within one (1) business day to patients who have recently discharged from an inpatient setting.
• Conducts telephonic assessments of discharged patients to identify unmet physical, psycho-social and/or behavioral needs.
• Assesses patient’s understanding of discharge plans and provides additional education as indicated. Instructs patient to take discharge instructions with them to their 7- day PCP/BH follow up appointment.
• Provides education to the patient/caregiver regarding the management of disease processes and signs & symptoms to report or escalate to a clinician. Provides phone number to Legacy’s After-Hours Nurse Line.
• Ensures the patient has received and understands how to administer newly prescribed medications.
• Starts the medication reconciliation process by collecting the names of current medications and comparing to the medications listed within the electronic medical record (EMR). Provides education and instructions regarding the medication regimen. Documents findings and instructions within the appropriate system for review by PCP or BH Provider.
• Ensures the start of care of prescribed services such as home health and/or durable medical equipment (DME).
• Facilitates the scheduling of a post discharge follow up visit with the assigned PCP or BH provider to occur within 7 days of discharge; Refers the patient to the appropriate care team member to assist with transportation needs.
• Refers patients who have ongoing physical, social determinants of health (SDOH) and/or behavior health needs to the care management team for follow-up.
• Refers patients who have excessive Emergency Room and/or Inpatient utilization patterns to Care management.
• Collaborates with the patient’s care team including, primary care team, specialists, home care, hospital team, managed care organization and any others involved with the patient’s care to optimize clinical outcomes.
• Maintains required medical documentation for transition of care activities in the designated system.
• Follows standards of work and consistently maintains department established timeframes for case completion.
• Documents and reports all quality and patient safety events by recording and adhering to all of Legacy Community Health’s safety reporting guidelines.
• Escalates any barriers to obtaining positive outcomes to supervisor or manager the same day.
• Participates in the refinement and/or development of new standards of work.
• Maintains awareness of key performance indicators/metrics and manages caseloads through coordinating interventions to prevent avoidable ER visits, hospital admissions and readmissions.
• Attend staff meetings and education offerings both in person and via teleconference/online as required.
• All other duties as assigned.

Education & Training Requirements

• Registered Nurse with an active, unrestricted Texas licensure
• State Board recognized nursing education
• 3-5 years acute clinical experience
• 1-2 years case/care management or utilization review experience

Work Experience

• Experience with all patient populations, including, Commercial, Medicaid & Medicare
• Computer literacy: Ability to operate computer programs and work within various documentation platforms
• Strong customer service skills to coordinate service delivery including proactive identification and resolution of issues that will promote positive patient outcomes
• This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management

Benefits

• Medical, Dental, and Vision insurance
• Long-Term Disability insurance
• Life insurance and AD&D
• 403(b) retirement plan
• Employee Assistance Plan
• Subsidized gym membership
• 24-hour travel assistance
• Paid Time Off 
• PTO Exchange Program
• Company holidays
• Bereavement Leave
• And more!