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Transitional Care Associate
3 months ago
**Primary City/State**:
Glendale, Arizona
**Department Name**:
Case Mgmt-Hosp
**Work Shift**:
Day
**Job Category**:
Clinical Care
As a Transitional Care Associate, you will facilitate the safe and timely transition from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care program. You will also facilitate discharge plan for the transition of care and services into the designated setting or service. Additional responsibilities include providing on-site or telephonic discharge arrangements to post-acute and community services. You should be willing to work collaboratively with care coordination team members to identify any barriers to a safe discharge, and works with patient/family to provide clear communication regarding discharge plan.
This is a full time position. Hours are 7AM to 5:30PM, 4/10 hour shifts per week. This is a self scheduling department and staff work a rotating weekend every third weekend and cover 1 major holiday and 1 minor holiday per year.
Banner Health’s premier West Valley Level I Trauma for adults and Tertiary Care destination for all ages. Banner Thunderbird Medical Center (BTMC) and Banner Children’s Hospital at Thunderbird provide a preferred destination for surgical, oncological, cardiovascular, neuroscience, orthopedic, pediatric, and women and infant services achieved through best-in-class 5-star CMS rating to provide patients with high quality, safe care for the best possible experience. Our campus is one of the largest campuses in the Banner network with over 3000 employees. BTMC was voted Best of the Best in 2023 by Banner Health out of 30 hospitals. This is the most prestigious award one of our largest hospitals can receive for consistently meeting our annual targets. If you would like to contribute to truly leading edge caring, we invite you to bring your experience and skills to Banner Thunderbird.
This position facilitates the safe and timely transition of clients from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care or community program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides on-site or telephonic discharge arrangements to post-acute and community services.
CORE FUNCTIONS
1. Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting. Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.
2. Facilitates/ implements the care plan with proposed interventions in collaboration with healthcare team. Collaborates with all members of the healthcare team to implement, manage and communicate the transition of care arrangements.
3. Participates in performance improvement projects, Banner initiatives and performs data collection for measurement of projects as assigned.
4. Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.
5. Assist and support patients and families in making appropriate arrangements for the post-acute plan. Performs follow-up calls to patients and providers as indicated and report any concerns to leadership.
6. Serves as an intermediary when providing community resources to patients, caregiver, and families. Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipated discharge date and potential care settings.
7. Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.
8. Employee has freedom to determine how to best accomplish functions within established procedures and implements the discharge plan under the delegated authority of a provider, licensed MSW, registered nurse or other licensed healthcare professional. Confers with supervisor/manager on any unusual situations and communicates plans and activities for patient discharge across the care continuum. Internal customers: Post-acute services team members and all levels of nursing management and staff, medical staff, and all other members of assigned facility interdisciplinary health care team. External customers: home health agencies, nursing homes, insurance providers, group homes, assisted living facilities, hospice, long-term acute care hospitals, inpatient rehabilitation facilities, volunteer agencies, county/governmental agencies and medical supply companies and others as required.
MINIMUM QUALIFICATIONS
A Bachelor’s degree in social work or related degree or a Licensed
