The Transitions Coach is key to ensuring safe and successful transfers in the movement of patients (“members”) across the care continuum. The Transitions Coach serves as the facilitator of interdisciplinary collaboration across a member’s transition by working with the professional staff in a care setting (e.g., hospital), ConcertoHealth’s multidisciplinary team of case managers, disease managers, Utilization Management Staff, the member’s Interdisciplinary Care Team (ICT), if applicable, and the member and/or the member’s family/caregiver(s).
The primary roles of the Transition Coach are to ensure a safe transition to the least restrictive and most inclusive setting of the member’s choice and to encourage self-management and direct communication between the member and their providers. The Transition Coach engages in interventions to mitigate the risk of inpatient readmissions, Emergency Room visits and/or movement to an institutional setting. The Transition Coach will connect with members in person, over the phone and at the provider’s office to better understand their pre- and post-transition needs.
Member Planning and Monitoring Activities:
Compliance-Related Care Management Activities: