Post Discharge Facilitator

The Post Discharge Facilitator supports DSRIP Project 2.b.iv (Care Transitions) by providing post discharge facilitation and coordination of services for patients at higher risk of readmission, with the goal of averting preventable 30-day readmissions. Core responsibilities include: Follow up phone calls and community-based visits as needed for higher risk patients post-discharge Supportive health coaching Facilitation of post-discharge services and community resources.