Transitional Care Assistant

In this role, you will:

Facilitate/arrange the client’s transportation home utilizing local transportation services and/or transports client’s home by driving agency vehicle when needed.
Support clients in the comprehension and implementation of hospital discharge instructions and create an individualized plan of care following agency assessments and client needs surveys.
Complete/arrange errands to meet client’s physical needs to support their recovery at home (nutrition, medication, medical supplies, equipment, etc.) as required, in accordance with established service plan.
Plan, arrange, procure, or perform home management duties (cooking, cleaning, laundry, etc.), in accordance with established service plan and in advance of discharge when identified.
Facilitate client and caregiver engagement., i.e., providing applicable information on client related issues surrounding transitions from hospital to home and/or prevention of hospital admission and readmission.
Communicate recommendations and support clients, care givers and those in the circle of care to address and repair safety concerns.
Provide companionship in cases where older adults suffer from social isolation.
Complete risk analysis of home and evaluate client’s risk of Falls using standardized Risk Assessment tool.
Support clients post-discharge to remove barriers and reduce risk in accessing resources (pharmacy blister packs, assistive devices, referrals, etc.) and for follow up discharge-related appointments.
Provide system navigation for clients and caregivers.
Communicate orally and document according to standards of documentation electronically; concerns, observations and/or needs of clients in appropriate database and to the Program Coordinator or designate.