Director of Transitional Care and Clinical Development

SWING BED PROGRAM

Leadership, Care Management & Program Performance Expectations

Director of Transitional Care & Clinical Development + Care Manager

Program Identity: Transitional Care First

CCMSD's program is a Transitional Care Program that serves eligible patients under the Critical Access Hospital Swing Bed benefit. "Swing Bed" describes the regulatory and reimbursement mechanism; "Transitional Care" describes the patient experience, clinical purpose, and program identity. The program is designed to bridge the period between acute hospitalization and the patient's safest, most appropriate next destination-most often home-through skilled nursing, rehabilitation, interdisciplinary care coordination, patient and caregiver preparation, and deliberate transition planning.

The central program expectation is not simply to maintain Swing Bed census. It is to accept appropriate patients, establish meaningful recovery and transition goals, actively advance each patient toward those goals, remove barriers, prepare the patient and caregiver for the next level of care, and execute a safe, timely transition. Census growth and responsible utilization support the sustainability of that mission.

1. Purpose and Operating Model

The CCMSD Transitional Care Program is designed as a coordinated transitional-care program with clear ownership across the full patient and program cycle. The Director of Transitional Care & Clinical Development has administrative ownership of the program. The Care Manager has primary day-to-day ownership of patient progression after admission. These roles are complementary, not duplicative, and are expected to function as a tightly coordinated team.

DIRECTOR: OWNS THE PROGRAM

CARE MANAGER: OWNS PATIENT PROGRESSION

Builds, leads, grows, standardizes, measures, and protects the Transitional Care Program. Owns referral development, incoming referrals, census strategy, authorization systems, compliance infrastructure, QAPI, and program development.

Coordinates the admitted patient through the program. Owns day-to-day care management, IDT coordination, utilization/continued stay, discharge planning, patient/family communication, and transition execution.

2. Director of Transitional Care & Clinical Development - Primary Expectations

• Maintain administrative ownership and overall accountability for the CCMSD Transitional Care Program.

• Maintain real-time awareness of census, available capacity, anticipated admissions, expected discharges, and active referral opportunities.

• Actively develop referral relationships and maintain a sustainable referral pipeline; serve as the primary organizational contact for incoming Swing Bed referrals.

• Coordinate each referral from inquiry through clinical/operational review, payer requirements, acceptance or denial, transfer arrangements, and admission.

• Develop and maintain standardized payer authorization, financial-clearance, utilization, policy, regulatory, documentation, and contingency workflows.

• Monitor regulatory requirements, maintain survey/audit readiness, identify compliance gaps, and coordinate corrective action and education.

• Maintain program-level oversight after admission, including utilization, payer requirements, length of stay, discharge barriers, and anticipated bed availability.

• Lead referral-source development, strategic clinical/program development, QAPI, dashboards, performance reporting, and improvement initiatives.

• Identify system-level barriers that limit admissions, progression, discharge, or growth and coordinate organizational solutions.

• Protect the administrative focus of the role. Routine nursing staffing, scheduling, personnel management, and bedside coverage remain outside the primary function of this position.

3. Care Manager - Primary Expectations

• Maintain active day-to-day oversight of each assigned Swing Bed patient, including skilled need, goals, payer requirements, barriers, anticipated length of stay, and expected discharge date.

• Review accepted patients before or at admission and complete or coordinate required assessments, including Transition Planning Initial Assessment, LACE, PRAPARE, BOOST/readmission assessment, and PASRR when applicable.

• Begin discharge planning at admission and actively resolve barriers throughout the stay rather than waiting for coverage or authorization to end.

• Schedule, organize, and facilitate Swing Bed IDT meetings; track assigned actions and follow them through completion or escalation.

• Perform or coordinate InterQual/continued-stay review; monitor skilled need, supporting documentation, payer authorization periods, and discharge readiness.

• Coordinate equipment, medications, oxygen, home health, outpatient services, transportation, follow-up, caregiver training, community resources, and placement needs.

• Serve as a consistent care-management contact for patients and authorized family/caregivers and maintain timely documentation in Cerner.

• Provide complex acute-care discharge-planning support when needed without compromising primary Swing Bed Care Management responsibilities.

• Identify recurring patient-level barriers, risks, delays, payer issues, and improvement opportunities and communicate them promptly to the Director.

• Protect the administrative/care-coordination focus of the role. The Care Manager is not routinely included in bedside staffing or used to meet scheduled minimum nursing coverage.

4. Role Boundaries - Who Owns What

Function

Director

Care Manager

Referral-source relationships & outreach

PRIMARY OWNER

Supports only when specifically requested

Incoming Swing Bed referrals & pipeline

PRIMARY OWNER

Temporary coverage when Director absent/delegates

Clinical/operational/payer referral coordination

PRIMARY OWNER

Provides patient-level information/support as needed

Admission readiness & handoff

Coordinates admission readiness

Assumes active care management at/around admission

Daily patient progression

Program oversight

PRIMARY OWNER

IDT meetings

Oversight / removes system barriers

PRIMARY OWNER - schedules, facilitates, follows actions

Utilization / continued stay

Sets system; program oversight

PRIMARY OWNER for patient-specific monitoring/reviews

Authorization

Builds workflow; escalation; trend monitoring

Tracks patient-specific periods and documentation needs

Discharge planning

Program oversight / system barriers

PRIMARY OWNER

Policies / regulatory readiness

PRIMARY OWNER

Applies standards; identifies gaps

QAPI / dashboards / program metrics

PRIMARY OWNER

Provides accurate patient-level data and barrier trends

Acute-care discharge support

Program/system support as appropriate

Provides complex discharge support as capacity allows

Routine bedside staffing

Not a primary function

Not a routine function

5. How the Two Roles Must Function Together

• Daily alignment: Maintain brief, reliable communication regarding census, active referrals, anticipated admissions, authorization status, patient progression, discharge barriers, expected discharge dates, and available capacity.

• Clean handoff at admission: The Director owns the referral and admission process through readiness for arrival; the Care Manager assumes primary ongoing care-management coordination once the patient enters the program.

• Closed-loop escalation: The Care Manager identifies and escalates barriers that cannot be resolved at the patient-care level. The Director owns coordination of system-level, interdepartmental, payer, referral, or leadership intervention.

• Capacity loop: The Care Manager provides realistic expected discharge dates and identifies delays early. The Director uses that information to develop referrals and fill anticipated openings.

• Authorization loop: The Director maintains the authorization system and escalation pathways. The Care Manager monitors patient-specific authorization periods, documentation needs, and continued-stay status so deadlines are not missed.

• Quality loop: The Care Manager identifies recurring operational problems from daily patient management. The Director aggregates trends, leads QAPI, changes workflows/policies, and evaluates whether changes improve performance.

• Coverage without ownership drift: Each role should understand the essential functions of the other well enough to provide limited continuity during absence; temporary coverage does not permanently transfer role ownership.

• No silos: Both roles communicate directly and professionally with Nursing, Therapy, providers, Pharmacy, Dietary, Revenue Cycle, Quality/Risk, patients/families, and referral partners as appropriate to their responsibilities.

6. Standard Program Workflow: DEVELOP  REFER  ACCEPT  ADMIT  MANAGE  TRANSITION  REFILL

Stage

Accountable Lead

Expected Result

DEVELOP

Director

Build referral relationships, capabilities, workflows, education, and program infrastructure.

REFER

Director

Maintain the referral pipeline and serve as the primary referral contact.

ACCEPT

Director

Coordinate timely clinical, operational, capability, and payer review for an admission decision.

ADMIT

Director + Care Manager

Director coordinates admission readiness and handoff; Care Manager transitions the patient into active care management.

MANAGE

Care Manager + Director oversight

Care Manager coordinates daily progression, IDT, utilization, payer tracking, patient/family communication, and discharge planning. Director addresses program/system barriers.

TRANSITION

Care Manager + Director support

Care Manager coordinates safe, timely discharge; Director resolves system barriers and incorporates anticipated capacity into referral planning.

REFILL

Director

Use anticipated capacity to pursue the next appropriate admission and sustain census.

7. Final Program Performance Expectations

A. Census, Referral & Access

• Maintain appropriate utilization of available Swing Bed capacity and minimize avoidable unused capacity.

• Maintain an active, measurable referral pipeline with repeat and newly developed referral sources.

• Provide timely referral decisions and minimize avoidable delay from acceptance to admission.

• Track lost referrals and reasons; develop corrective strategies for preventable losses.

B. Patient Progression & Outcomes

• Every patient admitted to Transitional Care under Swing Bed status has a clearly understood skilled need, individualized goals, anticipated discharge destination, barriers, next actions, responsible parties, and expected discharge date.

• Discharge planning begins at admission; avoidable days and preventable discharge delays are actively addressed.

• IDT meetings occur consistently, include appropriate disciplines and patient/family participation, and result in closed-loop action items.

• Transitions are coordinated safely with required equipment, services, medication plans, education, follow-up, and post-acute resources in place.

C. Utilization, Payer & Financial Stewardship

• Continued-stay requirements and medical necessity are reviewed proactively using approved criteria.

• Payer authorization periods and documentation requirements are tracked before deadlines; delays and denials are escalated promptly.

• Authorization turnaround, denials, delays, payer-related lost admissions, length of stay, and avoidable days are trended for improvement.

D. Compliance & Quality

• Required assessments and documentation are timely, accurate, complete, and survey-ready.

• Swing Bed policies, workflows, forms, education, and regulatory resources remain current and standardized.

• Program and patient-level data are used for QAPI, corrective action, education, and measurable process improvement.

E. Communication & Accountability

• Director and Care Manager maintain continuous, reliable communication and clearly hand off responsibility at defined transition points.

• Barriers are not merely documented; they are assigned, followed, resolved, handed off, or escalated.

• Role boundaries are respected so referral/program-development work and patient-through-program care management both receive dedicated attention.

• Performance is evaluated with recognition of factors outside either role's direct control, including patient choice, clinical appropriateness, payer determinations, staffing, organizational capacity, and service availability.

8. Core Success Measures

• Average daily Swing Bed census and occupancy/utilization rate

• Referral volume and growth by source

• Acceptance and referral-to-admission conversion rates

• Referral response/decision time and acceptance-to-admission time

• Lost referrals and documented reasons

• Authorization turnaround, denials, delays, and reasons

• Average length of stay and avoidable days/delays

• Anticipated versus actual discharge dates

• Discharge disposition, readmissions, and unplanned acute transfers

• Repeat and newly developed referral sources

• Documentation/compliance audit findings and corrective-action completion

• Patient/family communication and transit