To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
In collaboration with interdisciplinary team is responsible for managing the patient population with complex discharge barriers. Coordinates appropriate resources to facilitate and ensure the patients progress through the continuum of care from hospital discharge through post-hospital care. Provides assessment, intervention and follow up in collaboration with post acute care providers as required to expedite the discharge process therefore impacting patient flow through post acute continuum; patient, family, provider satisfaction; decreased length of stay and improved quality.
- 1. In collaboration with the hospital Care Management team and post acute providers, develops the overall plan of care /guidelines and communicates plan to members of the patient care team for select patients with complex discharge needs.
- 1.1 Reviews clinical records to obtain demographic and financial information and performs expert biophysical assessment appropriate to plan of care.
- 2. In collaboration with the assigned Care Manager and/or social worker at the post acute care facility.
- 2.1 Acts as liaison between patients, families, hospital staff and community agencies to promote communication and facilitate discharge planning back to home, other facility, agency or country of origin
- 3. In collaboration with Post Acute Care leadership, maintains a professional development plan.
- 3.1 Attends educational seminars to maintain and meet expectations.
Must hold professional licensure such as Registered Nurse or Social Worker with valid CT license or eligible.
Five to seven years experience in complex healthcare setting. Experience in Post Acute Care, complex management of underserved populations such as homeless, undocumented and under insured. Epic experience preferred.
Must hold professional licensure such as Registered Nurse or Social Worker with valid CT license, or eligible.
Excellent interpersonal, communication and leadership skills. Ability to work collaboratively and independently. Demonstrated personal maturity and good judgement. Expertise in complex case management, data collection, change management, process improvement, safety. Expert knowledge in information systems such as Helix and Epic and external resources such as Area on Aging, Medicare programs, etc.
Ability to travel across state.