Care Transitions Specialist
1 week ago
Hours Per Week: 35
DUTIES AND RESPONSIBILITIES:
JASA's Care Transitions Specialist (CTS) will coordinate, screen and facilitate the provision of home and community-based support services to improve hospital to home care transitions to avoid preventable 30-day readmissions. The CTS, an International Medical Graduate, must have the capacity to work across home, community and clinical settings, including in-hospital.
The CTS must be available to meet patients/caregivers and the hospital discharge team on-site to enable a warm hand-off. The Care Transitions Specialist also will conduct in-home assessments with the following objectives:
- Identify home-based issues that may be linked to readmission risk
- Provide direct services and referrals to support stable home based functioning, focusing on:
- Medication/DME (other supplies): Ensure patient has medication, supplies and equipment and understands prescribed use
- Patient Education: Ensure patient is aware of their health conditions and how to manage them, and understands red flags and health risks
- Health Care Provider Communication and Coordination: Ensure patient has a primary care provider (PCP), update PCP on patient status, assist patients with follow up appointments
- Screen for and identify social and mental health needs of patients and provide closed-loop referrals
- The provision of in-hospital (or other clinical setting and, in-home assessments of the social and emotional needs of the older adult client and their family, utilizing prescribed standardized assessment instruments;
- The provision of a full range of social services for the older adult client(s) and family, including:
- Education and support to improve disease self-management and prevent avoidable hospital use
- Screening of client eligibility, application for, and advocacy in securing benefits and entitlements
- The arrangement for direct provision of services such as transportation, homecare services, meals on wheels/nutrition services, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, medical and psychiatric examination and therapy, housing, etc.
- Referral, development of relationships and cooperative work with other community agencies, to meet the needs of clients
- Informing supervisors of situations of crisis or circumstances where the worker requires further guidance.
- Participating in training and team meetings.
- Collecting and inputting patient data into JASA's Electronic Health Record system and assisting with analytics, reports and statistics, utilizing computers.
- Performs such other duties as assigned.
- International Medical Graduate or equivalent.
- Graduate of an Accredited College or University with B.A./B.S. degree
- Good writing/record keeping skills.
- Ability to read, write, speak, understand English.
- Ability to read, write, speak, understand Spanish (preferred).
- Must be computer literate, including ability to learn and use program-specific software.
- Ability to travel to clients' homes using mass transit, however, driving may be required for certain home visits.
- Able to negotiate any steps and barriers in clients' residences.
- Hospital discharge planning or other health care experience preferred.
- Understanding and appreciation of the roles of race, religion, ethnicity, sexual preference, and individual values as they relate to serving clients and families.
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