Care Transition Specialist Lead

1 month ago

Boston, Massachusetts, United States Brigham and Women's Hospital Full time
Patient Care Management

The Care Transition Specialist Lead plays a pivotal role in facilitating seamless transitions for patients from inpatient to outpatient settings. This involves proactively coordinating referrals, ordering necessary equipment and medication, and completing relevant forms to ensure a smooth discharge process.

As a key member of the Mass General Brigham - Care Continuum Management team, the Care Transition Specialist Lead acts as a consultant to hospital staff, patients, and families, providing guidance on the placement process and access to community resources.

The Specialist is responsible for establishing homecare plans in conjunction with the Care Coordination Manager, documenting the plan and progress in the medical record, and assisting with obtaining medications or DME needed at discharge.

Additionally, the Care Transition Specialist Lead coordinates and expedites final transfers with staff, patients, families, and facilities, while also updating staff on new facilities, services, and resources, and maintaining a library of reference materials.

Referral Management

The Care Transition Specialist Lead coordinates long and short-term placements to extended care facilities, documenting discharge plans in electronic referral systems or via fax, and monitoring and managing follow-up or escalations as needed.

Actively communicating and collaborating with a wide range of social agencies, clinics, schools, and courts, the Specialist plans, when appropriate, a continuation of previous utilization management services and/or agency for continuity of care.

Interpreting insurance coverage and making recommendations for short-term rehab or non-acute options, the Care Transition Specialist Lead develops relationships and maintains contact with appropriate facilities and resources, occasionally visiting sites.

Evaluation

The Care Transition Specialist Lead monitors quality of care in ECFs, home/community agencies, and reports findings to the Program Manager.

Maintaining current information on non-acute provider agencies, including SNF, sub-acute, acute rehab, and chronic facilities, the Specialist acts as a resource to staff, patients, and families concerning this information.

Providing follow-up and ongoing assistance with assessing community and ECF services, the Care Transition Specialist Lead follows up and tracks utilization of referred patients for evaluation purposes and provides feedback to the Program Manager.

Performance Improvement

The Care Transition Specialist Lead maintains a statistical database on escalations, referrals, admissions, and homecare/community agency resources and tracks discharge process utilized by the patient.

Participating in the development and monitoring of performance standards for extended care facilities and homecare/community agencies, the Specialist maintains documentation to support findings.

Maintaining contact with State regulatory agencies and non-acute care provider agencies to keep current on the rules and regulations needed to facilitate discharge planning, the Care Transition Specialist Lead ensures seamless transitions for patients.

Analysis, Administrative, and Training Duties

The Care Transition Specialist Lead analyzes operational data to evaluate performance as directed by department administration.

Supporting the documentation of outcomes and ideas generated through task forces and initiatives as it relates to the department's objectives and specifically related to Post-Acute as directed and overseen by department administration, the Specialist meets expectations related to collection and synthesis of relevant data, communication summaries, and tracking of tasks and related outcomes as directed by department administration.

Managing ad hoc projects as directed by department administration, the Care Transition Specialist Lead facilitates process and technical training for Care Transition Specialists and other department roles as directed by department administration.

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