GENERAL SUMMARYWorks to ensure accurate and appropriate gathering of demographic and clinical patient information prior to discharge from the hospital and start of care. Assesses patient for appropriateness of Henry Ford at Home services, identifying support required regarding the patient's needs. Is responsible for educating, developing and strengthening relationships with referral sources, senior leaders, and Henry Ford at Home providers. Coordinates and assists hospital/facility case managers in ensuring a smooth transition for patients from the inpatient setting and/or physician offices. Provides home infusion visits in patient homes and manage patient caseloads when applicable.PRINCIPLE DUTIES AND RESPONSIBILITIESIndependently participates in the clinical assessment, problem identification, and planning functions for patients who have been identified by the case management team, other health care facility personnel, physicians, or patients/families as possibly needing Henry Ford at Home products and servicesUses clinical assessment skills to determine the patient’s appropriateness for Henry Ford at Home services by reviewing the patient’s medical condition as well as the patient’s and caregiver’s potential ability to assist with aspects of the care plan, performing an assessment identifying required community services, and communicating the needs with the physician and other appropriate individuals.Collaborates and communicates with Henry Ford at Home leaders and staff to ensure appropriate and timely referrals. Performs patient and family education prior to start of care; provides information and education to patients and families prior to dischargeInterprets diagnostic data and incorporates data into the assessment. Assess health problems/perceptions of the client and or family and client’s expectationsCollaborates with referral sources to identify problems and resolutionsCoordinates patient discharge with hospital/facility case managers, including patient and/or family and other members of the health care teamDetermines appropriate frequency of nursing visits/duration based on patient needswhen applicableReviews and remains updated on knowledge of Henry Ford at Home criteria,Medicare conditions of participation, 3rd party payer information and CHAP guidelines.10.Acts as a consultant and subject matter expert to the health care facility staff, patients, caregivers and the community for information regarding various aspects of Henry Ford at Home products and services.CERTIFICATIONS/LICENSURES REQUIREDRegistered Nurse in the State of MichiganAdditional InformationOrganization: Community Care ServicesDepartment: HHC IntakeShift: Day JobUnion Code: Not ApplicableAdditional DetailsThis posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.OverviewHenry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .BenefitsThe health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.Equal Employment Opportunity/Affirmative Action EmployerEqual Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.