Director of Self Management Education – ALG

Director of Self Management Education


Candidate should be a nurse or Social Worker who has management experience and MDS/PPS knowledge.  Patient and family education, and patient advocacy is a plus.


Clinical Compliance

  1. Monitors admissions process to ensure that…
    • All medications have been sent to the pharmacy in a timely manner
    • Diet has been communicated to the dietary department
    • Nurses, CNAs, Rehab are aware of new admissions and has greeted the new patient in a timely manner
  2. Monitors clinical documentation daily
    • Ensure that nurses are documenting based on the skilled need(s)
    • Ensure that careplans are updated according to clinical needs
  3. Ensures compliance with the Clinical Systems for all Post Acute patients
  4. Ensures compliance with consents, as appropriate

PPS Management

  1. Manages PPS process for Post Acute patients
  2. Ensures that the Post Acute patients receive nursing care in order to be successful when they are discharged to home


  1. Work directly with the Admissions Department to understand the clinical needs of pending admissions
  2. Communicate with internal Department Heads about the needs of upcoming admissions
  3. Communicate with Therapy Director on daily basis
    • Ensure that therapy goals are incorporated in nursing staff practice and nursing restorative program are implemented

Transition Duties

  1. Meets with all admissions to provide a facility orientation.  First meeting should occur within 1 hour of admission
  2. Conducts follow up meeting with patients and their families after 24 hours to ensure that all needs are met
  3. Identifies any problems/concerns and follows up with those concerns until resolved.
  4. Spends TLC time with high intensity patients and families
  5. Identifies all patients scheduled for discharge and meets with them 3-4 days pre discharge
  6. Develops plan of care with pt and charge nurse
    • Identify and develop pt education needs
    • Monitor progress of pt education
  7. Ensures that transition plans are in place for discharge, including Transition U and medication reconciliation process
  8. Provides coaching with patient and family to increase the likelihood of their success at discharge
    • Assesses their understanding of why they were hospitalized
    • Assesses their recognition of Red Flag systems that could have avoided the hospitalization
    • Interacts with patient and family to ensure that they recognize Red Flags that can be avoided
    • Subsequent hospital readmissions
    • Interacts with patient and family to ensure that they understand how to communicate with their healthcare practitioner
    • Interacts with patient and family to reconcile their medications prior to discharge
  9. Conducts the 24 hours admission survey and the discharge satisfaction survey
  10. Contacts patient and family within 24 hours of discharge to ensure smooth transition home.
  11. Follows up with patients around day 20 post discharge to ensure that the transition was smooth and to determine if they need additional post acute services.

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