Clinical Solutions and Readmission Prevention Coordinator

At 21st Century Home Health Services (HHS), we are committed to treating every patient with the same empathy, compassion and understanding that we would show our family. With over 350 employees, we are the largest Home Health Agency in San Francisco and the fastest growing in the Bay Area. We provide care to over 2,000 patients in San Francisco, San Mateo, Santa Clara, Contra Costa and Alameda Counties. We are proud to share that we have recently expanded into Solano, Napa and Santa Cruz Counties.
Our Clinicians are not only dedicated to the patients we serve, but to each other. The proof is in our outcomes: Hospital readmission rates for 21st Century HHS are consistently under 10% while the industry average is over 15%. We have the highest Medicare classification rating of 5-stars, based on a set criteria determining excellence.
As a Clinical Solutions and Readmission Prevention Coordinator, you will play a key role in our mission to "Educate, Enhance, Empower" by analyzing, recording trends, and developing strategies aimed at reducing hospital readmissions. This role emphasizes proactive data collection and analysis to identify common causes of readmissions, suggesting alternative approaches to care, and supporting care teams by providing evidence-based recommendations. You will also assist in identifying opportunities for improvement in care protocols to enhance patient outcomes and prevent readmissions.

Key Responsibilities:

• 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.
• Provide support through a helpline dedicated to assisting nursing staff with clinical skills and problem-solving challenges.
• Collect and analyze patient data, including call topic statistics, to identify trends, patterns, and risk factors.
• Identify recurring issues and opportunities for improvement based on the nature of calls and common challenges reported.
• 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.

Qualifications:

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field (Master’s degree preferred).
• Valid nursing or healthcare professional license
• Minimum of 3 years of clinical experience, with at least 1 year in a home health or similar setting.
• Demonstrated experience in analyzing patient care trends and providing data-driven care recommendations.
• Strong analytical and problem-solving skills with the ability to interpret complex datasets.
• Excellent communication and collaboration skills for working with multidisciplinary teams.
• Commitment to improving patient outcomes through proactive data analysis and protocol improvements.

What We Offer:

• Competitive salary and comprehensive benefits package.
• Opportunities for professional growth and development within a mission-driven environment.
• The chance to make a significant impact on patient outcomes and heal