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Hospital to Home Liaison

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Burlington, United States Minuteman Senior Services Full time

**Position Summary**: Based mainly at Emerson Hospital and reporting to Minuteman Senior Service’s Assistant Director, the Hospital to Home Liaison (HHL) works hand in hand with hospital staff at the inpatient level and Emergency Department (ED) to leverage collective expertise and skills to enable effective care coordination and successful care transitions to the home. S/he will expedite access to home and community-based care services for Emerson Hospital patients through Minuteman Senior Services or other local ASAPs (depending on the patient’s community of residence). The HHL will be responsible for providing services to eligible consumers in various environments and locations including but not limited to hospitals, nursing homes and private residences as determined by the needs of the program.

**RESPONSIBILITIES include**:

- Visit patients across settings (including in their home) to review community options and support the plan of care and family caregivers and provide information back to the hospital, physician practice, SNF/Rehab and HHA about the patient’s home environment and social supports.
- Contact SNFs and Home Care to coordinate care and avoid duplication of services.
- Collaborate with other MSS care managers and other consumer services team members.
- Communicate any relevant data about current service plans for shared patients to help improve quality and continuity of care and communication across the continuum.
- Complete all necessary documentation in a timely manner to meet the needs of the program.
- HHL will engage in and support regular communication regarding patients, outcomes, issues, needs, and concerns with Emerson Hospital staff.
- Participate in collaborative meetings at the hospitals and CBO as outlined by the Assistant Director to build relationships, improve an expedited referral process, identify barriers and trends to better serve the consumer and key stakeholders at the hospital to impact program outcomes.
- Social Work experience working in community-based settings, LSW preferred.
- Minimum of 2 years’ experience working with older adults and families required.
- Familiarity with MS Office Suite including Word and Outlook as well as navigating and entering information into databases.
- Assessment of social determinant of health needs and service coordination experience,
- Motivational Interviewing experience preferred, but not required.
- Reliable car and valid driver’s license to conduct home visits.