This track is required for those in prior Transition Coordinator and SNF Liaison roles OR New Hires in facilities that HAVE transitioned to the new model.  

Below is the content contained within this module: 

Home Care: CTM Overview, Multi-Patient Task List, and Home Health and Hospice PowerChart/Cerner
Home Infusion and Durable Medical Equipment Referral Orders in Cerner/PowerChart
Identifying UPMC Home Healthcare Curtailments
Important Programs for UPMC Discharge Plan Managers
Care Management Overview
Care Coordination
Financial Risk and Reimbursement
Determining Surrogate Decision Makers
Level of Care Determination for Post-Acute Care
Victims of Abuse: Identifying and Reporting
Substance Use, Behavioral Health, and SAFE-T
End of Life
Discharge Planner eRecord Review
Discharge Follow-Up Phone Calls