JOB SUMMARY: Collaborates with members of the healthcare team, community resources, and with the patient/patient family to promote optimal outcomes for the patient across the continuum of care. Maintains a smaller caseload that requires increased attention and intensive care coordination due to complex social dynamics, legal involvement, and connection with DSS/DDA. Formulates unique solutions to complex discharge planning issues (thinking outside the box). Assists with navigating through barriers that may be preventing the safe disposition of patients. This position is goal oriented with a high level of accountability correlated to the continuum of care, quality of care and patient satisfaction. Supports the success of the care coordination of this patient population with a high degree of professionalism and expertise.

1. Identifies high risk patients with complex needs early in the hospital stay to develop and implement a comprehensive plan of care to address and manage specific needs. Manages the care of patients/families through the healthcare system based on the individualized needs.

1. Coordinate with interdisciplinary team to develop, revise, (if necessary due to change in patient progress) and implement appropriate discharge interventions to ensure safety and care coordination.

1. Communicate with leaders any pertinent findings causing a delay in care coordination, safe d/c planning, and/or LOS.

1. Complete a thorough assessment with patient's history including medical, physical, social, emotional, psychological, and financial needs that will assist the care team in developing a care plan. Engage in goals of care discussions and completes Advance directives as identified.

1. Coordination of Legal prep sessions for any UCMC staff who are required to provide expert testimony in court for guardianship or other legal cases. Attends court for all guardianship cases and provides expert testimony during hearings and trial for guardianship or other legal cases.

1. Provide and review the appropriate community resources/services with the patient/family.

1. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.

1. Actively participates in Care Transition Rounds or provides detailed hand off to a co-worker participating in the CTR. Provides appropriate patient information to increase safe discharge plans and reduce LOS.

1. Works collaboratively to maintain active communication with physicians, nurses, utilization review team, and other members of the multidisciplinary team to effect timely, appropriate, patient management through the healthcare system. Makes recommendations for potential alternatives to care plan based on availability of resources and patient/family preferences.

1. Identify need for, arrange, and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and financial issues.

1. Develops and maintains collaborative relationships with the post-acute representatives to ensure safe and confidential and transfer is timely.

1. Initiates refer rals to home healthcare, infusion therapy, hospice, skilled nursing/rehab facilities, dialysis centers, durable medical equipment to facilitate timely transition to alternate levels of care.

1. Consistently evaluate and update current resources to ensure accurate and relevant information for all community resources for our patients/families.

1. Participates in identifying performance improvement opportunities and achieving the departments PI initiatives and goals.

1. Identifies safety events and report them in UM Safe tracking system.

1. Orients new team members and students.

1. Maintain professional development best practices and continuing education requirements for licensure.

1. Assist with special projects and other duties as assigned.