Transition of Care Nurse - Central

Grace At Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

The Transitions of Care (TOC) Nurse provides timely, telephonic clinical outreach to family members following acute care, skilled nursing, or facility-based discharges to support safe and effective transitions across care settings. This role focuses on reducing avoidable readmissions, closing quality care gaps, and improving patient outcomes through assessment, education, care coordination, and escalation as needed. The TOC Nurse serves as a critical clinical touchpoint during high-risk transition periods and collaborates closely with interdisciplinary teams to ensure continuity of care. This role supports value-based care objectives by improving utilization outcomes and quality performance.

Transitions of Care Outreach & Clinical Support: Conduct timely post-discharge telephonic outreach in accordance with established TOC workflows and timelines. Perform comprehensive clinical assessments to identify post-discharge risks, unmet needs, and barriers to recovery. Complete medication reconciliation, reinforce discharge instructions, and assess understanding of care plans. Educate family members on symptom monitoring, red flags, follow-up care, and self-management strategies. Coordinate follow-up appointments with primary care providers, specialists, and ancillary services as appropriate. Care Coordination & Escalation: Identify and escalate clinical concerns, care gaps, or social barriers to appropriate care team members. Collaborate with primary care practices, care managers, pharmacists, social workers, and other partners to ensure continuity of care. Facilitate referrals to community-based resources or internal programs to address identified needs. Document and communicate actionable information to support timely intervention and risk mitigation. Quality & Value-Based Care Support: Support closure of quality gaps related to transitions of care, medication adherence, and follow-up. Contribute to reduction of hospital readmissions, emergency department utilization, and total cost of care. Adhere to evidence-based TOC models and organizational protocols aligned with value-based care programs, including ACO and MSSP requirements. Participate in quality improvement initiatives and feedback loops to enhance TOC effectiveness. Documentation & Reporting: Accurately document all outreach, assessments, interventions, and outcomes in designated EHRs or care management platforms. Ensure timely, complete, and compliant documentation to support reporting, audits, and performance monitoring. Communicate key findings and trends to leadership and interdisciplinary teams as required. Professional Practice: Maintain active RN licensure and adhere to professional nursing standards and scope of practice. Participate in onboarding, training, and ongoing education related to transitions of care and value-based care models. Support a culture of patient-centered, high-quality, and accountable care delivery.