Purpose: The Post-Acute Hospital Registered Nurse Liaison will act as the key facilitator to assist the hospital in the discharge planning process for home health services; will maintain the standards of service excellence in the transition of the patient, from the hospital to the home setting, to achieve positive patient outcomes; will act as an educational and consultative resource to the institution concerning appropriate home care services and community resources; will act as an advocate for the patient and their family, maintaining the continuum of care from the hospital to the home setting. The Post-Acute Hospital Registered Nurse Liaison will be located in an assigned hospital and may be required to cover other acute care hospitals.
Acts as an advocate for the patient and/or their family.
Adheres to CMMS Centers for Medicare /Medicaid Services and Commercial payers' standards, policies and procedures.
Adheres to company and departmental standards, policies and procedures.
Assess the patient appropriateness for home care services and Offers Freedom of Choice to patients according to the UPMC Health system policy and procedure. Documents the patient's choice according to the institution standards.
Assists and secures Physician Attestation form as per the Patient Protection Affordable Care Acct also referred to Face to Face encounter.
Attends educational in services, departmental staff meetings, and mandatory training and UPMC Health System meetings as required.
Collaborates with the multidisciplinary team and servicing home health agencies to facilitate quality, cost-effective services in the home, while maintaining continuity of care and achieving positive patient outcomes
Communicates, in conjunction with the insurance verification department, the patient's insurance benefits and convey financial responsibility to the patient/family.
Completes Point of Care patient referral data and forwards all information to the servicing agency.
Completes other duties as assigned.
Complies with accepted ethical conduct and professional Standards of Nursing Practice.
Coordinates and communicates the home care arrangements to the multidisciplinary staff to ensure that all equipment, supplies, and services are in place along with documentation the electronic health record.
Educates the multidisciplinary team regarding the services available to assist the patient in the home setting.
Educates the patient and/or family regarding all services available in the home setting.
Follows established administrative and human resources policies and procedures to ensure compliance at all times.
Gives high priority to patient satisfaction and in meeting their home care planning needs.
Identifies issues and concerns the patient and/or family may have and assist in issue resolution.
Maintains current knowledge of appropriateness for home care in accordance with regulatory standards, i.e. TJC Standards, Federal/State regulations as well as Managed Care Organizations and other third party payer requirements
Maintains patient information and records confidentiality.
Maintains service excellence with internal and external contacts as participating in community programs.
Maintains the standards of excellence and acts as an educational and consultative resource to the institution.
Participates in UPMC Health System educational activities as a community services resource and educator.
Promotes and maintains the continuum of patient care from the hospital to home setting:
Provides information to the patient and/or family on the home care agency that has been chosen.
Registered Nurse required, licensed in the state of Pennsylvania.
Two years nursing experience in Long Term Care/Acute Care setting required.
Knowledge of home care qualifying guidelines and (1-2 years) home care experience preferred.