Description

Transition Coordinator
Sickle Cell Disease Program, Division of General Internal Medicine, SOM Department of Internal Medicine:

Virginia Commonwealth University (VCU) School of Medicine is a premier academic medical center located in the heart of Richmond. Accounting for almost half of VCU's sponsored research, the School of Medicine is internationally recognized for patient care and education.

The Transition Coordinator provides coordination of services related to transition age patients, which include assessments, case management, referrals and overall program development. This role will be a liaison between pediatric and adult sickle cell program, and ensuring the continuity of care of young adults with sickle cell disease.

This is a restricted position with no set end date; continued employment is dependent upon project need, availability of funding, and performance.

Core Responsibilities

Intervention/Case Management - 60%

• Conduct Transition Readiness assessments on transition aged patients (age 15-25) which includes assessing stress thresholds, understanding of chronic disease, disease management knowledge, and case management needs. This assessment is done for all incoming patients and must be repeated on an annual basis
• Work with both pediatric and adult sickle cell teams on educational/vocational planning, case management and other psychosocial issues
• Act as a liaison between transition age patients and adult sickle cell medical team as needed
• Work with community platforms on educational and vocational roles
• Engage in outpatient pediatric and adult clinics with patients and team members to support the patients in their day to day needs
• Participate in pediatric and adult social events for transition age patients and lead other platforms as needed, including leading the annual Transition Career Fair
• Based on assessments, create necessary learning objective plans with each patient as needed, treatment recommendations, referral to therapy and/or other social services and community-based organizations. Provide supportive counseling for transition age patients when appropriate
• Conduct on-going support groups for transition age patients to assist in processing difficult emotions related to transfer of care
• Conduct educational workshops for transition age patients to include topics such as: disease management, Sickle Cell 101, healthy relationships, grief processing, trauma responses, substance abuse, social services, anger management, daily living skills etc.
• Document all assessments, referrals, and supportive counseling notes in EPIC
• Work alongside Patient Navigators to assist transition aged patients in orienting to the adult sickle cell clinic, locations, processes, and care team when needed
• Work as a member of the adult multi-disciplinary team to collaborate with providers and patient navigators in ensuring improved patient care and outcomes
• Effectively communicates and navigates systems to include health care, social services, education and community resources to assure patients access and appropriate use of these services
• Identify problems and resources to help clients solve their problems with the goal of empowering the patient/family/others how to navigate
• Work in a community and hospital settings, or other designated settings, to ensure that the patients' needs are properly identified. This will include, but not limited to, home visitations, hospital visits, ED visits, other medical appointments and all other approved locations to work efficiently with the patient to provide stability. Currently this is a Hybrid model
• Establish and maintain a social media platform for patients and families
• Provide and support community activities for patients, which may occasionally require evenings or weekends.

Program Management & Support - 20%

• Is knowledgeable of the Patient Centered Primary Care Medical Home and assists the interdisciplinary teams in promoting patient centered care
• Work with interdisciplinary teams while patient is hospitalized to prepare for discharge and ensure medical follow-up is secured and provided for the patient's needs
• Works with patients to empower them to become an active participant in their health care
• Demonstrate skills in patient advocacy to assure access to care

Performance Competency & Standards - 10%

• Provides a supportive environment for patient to discuss issues that need addressed through bi-monthly support groups and activities (hybrid and in-person)
• Completes all documentation as required by the VCUHS team
• Attend all scheduled trainings, workshops and additional workshops as indicated by supervisor
• Documents and is competent in listening, share information 1:1 or in larger groups using establishes written and oral communication systems
• Reports to Senior Program manager or medical director for any pertinent observation or information

Administrative Responsiblities - 10%

• Performs other duties as assigned/or participates in special projects in order to support the mission of VCUHS and the department
• Planning for absences by ensuring coverage for patients
• Accepts alternate assignments as required