Hospital Liaison - Registered Nurse - Home Health

Sutter Health Alameda , CA 94502

Posted 2 months ago

On any given day, Sutter Care at Home touches the lives of thousands of individuals by bringing health care directly to patients where they live - at home.

From local, community-based offices throughout Northern California, the dedicated staff at Sutter Care at Home cares for more than 50,000 patients each year and serves an average daily census of over 18,000 patients.

We provide the most comprehensive range of home care services including skilled nursing, rehabilitation therapy, home infusion therapy, hospice and palliative care, medical social work, home medical equipment and respiratory therapy, home attendant and care management, and community flu and wellness programs.

Through competitive wages and benefits, flexible schedules, innovative care models, new technologies, and tuition reimbursement - Sutter Care at Home strives to be your "employer of choice."

Sutter Care at Home is the home health care and hospice affiliate of Sutter Health, one of the nation's largest not-for-profit health care systems.

The Sutter Care at Home Hospital Liaison facilitates admissions to Sutter Care at Home services by providing inpatient supportive care and seamless transition to home based care including, Home Health, AIM, or Hospice, depending upon the services available in that area. The Hospital Liaison assists the organization by assuring that the right care is provided at the right place and the right time.

To accomplish this goal of right care, right place and right time, the Hospital Liaison uses established criteria to:

a. evaluate the appropriateness of patients referred for home care services

b. confirm the level of care most appropriate for the patient

c. assess the patient's readiness for discharge

d. facilitate 'transition to home' planning including assessing post-discharge needs and developing and implementing transition to home plan

Holding continuity of care as a priority, the Liaison communicates and coordinates with the larger health care team supporting the patient including hospitalist, hospital case management and nursing, patient's physicians, and other healthcare providers involved in the patient's care at home. The Liaison will attend rounds, facilitate orders, evaluate patients' care (medical, psycho-social and practical) needs, including medical eligibility for services, anticipated needs for equipments, medication, and transportation.

The Liaison collaborates with the patients and their representatives, the patients' inpatient care teams, and outpatient care teams to identify patient/family needs and preferences as well as the overall care needs. The Liaison is responsible for helping the patients and their representatives determine person-centered goals.

The Liaison serves as a clinical resource for patients, families, physicians, and facility staff for appropriate home placement, medication reconciliation, goals of care and identification of necessary support at home, as well as problem solving barriers or challenges related to the patient returning home.


AA/AS required. BA/BS desired. Current California RN license; valid California driver's license; current auto insurance; current BCLS/CPR certification.



  • Minimum 3 years in nursing experience required.

  • Must have direct patient care experience within the last five years

  • One year experience in Home Health and/or Hospice setting must be within last three years

  • Recent experience in acute-care hospital setting; knowledge of discharge planning/case management strongly preferred.


  • Must have clinical knowledge and critical thinking ability to create a viable and effective patient transition plan and identify barriers in service, effectively conduct verbal or written patient assessments, carry out the referral process, and coordinate with other individuals involved in the plan of care.

  • Understanding of homecare and hospice services and regulations, Title XXII, Medicare Conditions of Participation, reimbursement systems, home health and/or hospice accreditation requirements.

  • Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.

  • Knowledgeable of how the range of home care services can help patients with a wide range of needs from post surgical care to mom/baby care to palliative care to end of life care.


  • Self-starter with a high degree of initiative, motivation, flexibility, energy and creativity.

  • Ability to work as part of a team as well as form harmonious working relationships with internal and external customers.

  • Excellent collaborative and problem solving skills with customers and management.

  • Excellent organizational skills.

  • Must have excellent telephone, interpersonal and written communication skills.

  • Strong commitment to teamwork and customer service, both internally and externally, is required.

  • Experience with Microsoft Office suite and electronic health record strongly desired.

  • Must be flexible with schedule including, but not limited to, department rotation for weekend coverage.

  • May be asked to work in field providing homecare services as per changes in business needs and as skills and training allow

  • Must be able to develop an organized work plan in a high-volume environment with rapidly changing priorities.

Special Requirements:

  • Must have current California Registered Nurse licensure (or higher), a current California driver's license, reliable transportation and proof of liability insurance.

  • Must be able to orchestrate successful, complex discharge plans.

  • Must have strong clinical assessment skills

  • Must be able to deal with challenging work environment with time demands and occasional conflicting priorities.

  • Must have influencing skills to support patient/family appreciating the value and importance of home based services to support their needs for Home Health, SIPS, Private Care, AIM and Hospice as necessary.

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Hospital Liaison - Registered Nurse - Home Health

Sutter Health