21st Century Home Health Services

Therapist

• Responsible for in the field oversight of clinicians who provide care and treatment to patients in their place of residence including performance evaluations and hiring.
• Handles incoming calls timely, and follows up as necessary to ensure appropriate actions are taken to meet the internal and external customer needs.
• Coordinates training and educational programs for nurses within the field to improve clinical outcomes and competencies.
• Assesses staff learning needs and formulates specific plans and goals for next evaluation period with employees, performs administrative call duties, and serves as a role model and resource for staff.
• Functions as the first point of contact for field clinicians to assist in patient care escalations etc.
• Coordinates at least bi-weekly Case Conferences with clinical team to discuss patients' progress and for revision of the care plan as needed to meet planned outcomes.
• Reviews and evaluates each case by reviewing the services provided by clinicians, conferences, record review, discusses and verifies impressions, instructs and guides clinicians to promote more effective performance and delivery of quality home care services, and is available at all times during operating hours to assist clinicians as appropriate.
• Reviews patient’s clinical diagnosis, medications, procedures and clinical course.
• Assists clinicians in establishing immediate and long-term therapeutic goals, in setting priorities, and in developing a plan of care.

Clinical Supervisor – Occupational Therapy

Events

• Collect and analyze patient data, including readmission statistics, to identify trends, patterns, and risk factors.
• Categorize and record common themes based on data from patient care records, helpline interactions, and clinical outcomes.
• Develop and propose data-driven alternatives to existing care protocols to address identified risks and prevent readmissions.
• Suggest adjustments and interventions to care teams that align with findings from data analysis and patient trends.
• Work closely with nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), home health aides (HHA), social workers (SW), and other healthcare professionals to gather insights from their care experiences.
• Provide feedback to clinical staff based on data analysis to help refine patient care strategies.
• Collaborate with clinical and educational leaders to ensure that training programs are aligned with current data findings on disease management, medication adherence, and patient care practices.
• Suggest improvements to training and education materials based on observed trends and gaps in care protocols.
• Continuously monitor and evaluate the effectiveness of readmission prevention initiatives, identifying areas where care improvements can be made.
• Use data visualization tools such as Pareto charts to clearly communicate common causes of readmissions and suggest targeted interventions.
• Assist in developing new protocols or refining existing ones based on data analysis, focusing on addressing common causes of readmission.
• Ensure that protocol changes are well-documented and communicated to the relevant teams to enhance care outcomes.
• Prepare and submit detailed reports on readmission rates, preventive measures, and care improvements to senior management and external partners, such as Kaiser, within 24 hours of discharge when required.

Readmission Prevention Coordinator, Registered Nurse

• Collect and analyze patient data, including readmission statistics, to identify trends, patterns, and risk factors.
• Categorize and record common themes based on data from patient care records, helpline interactions, and clinical outcomes.
• Develop and propose data-driven alternatives to existing care protocols to address identified risks and prevent readmissions.
• Suggest adjustments and interventions to care teams that align with findings from data analysis and patient trends.
• Work closely with nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), home health aides (HHA), social workers (SW), and other healthcare professionals to gather insights from their care experiences.
• Provide feedback to clinical staff based on data analysis to help refine patient care strategies.
• Collaborate with clinical and educational leaders to ensure that training programs are aligned with current data findings on disease management, medication adherence, and patient care practices.
• Suggest improvements to training and education materials based on observed trends and gaps in care protocols.
• Continuously monitor and evaluate the effectiveness of readmission prevention initiatives, identifying areas where care improvements can be made.
• Use data visualization tools such as Pareto charts to clearly communicate common causes of readmissions and suggest targeted interventions.
• Assist in developing new protocols or refining existing ones based on data analysis, focusing on addressing common causes of readmission.
• Ensure that protocol changes are well-documented and communicated to the relevant teams to enhance care outcomes.
• Ensure that all actions and data collection processes comply with federal, state, and local regulations regarding home healthcare and patient privacy.
• Prepare and submit detailed reports on readmission rates, preventive measures, and care improvements to senior management and external partners, such as Kaiser, within 24 hours of discharge when required.