JOB SUMMARY:

Provides Care Coordination and discharge planning services for all inpatients accessing care through the Univ. of Md. Upper Chesapeake Health. Completes psychosocial assessments, assists with treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinates and implements discharge services. Screens patients to identify anticipated needs, interacts with patients and families, so that a safe and timely care plan is achieved. Coordinates and implements discharge and post-acute services for inpatient caseload. Position requires coverage on holidays and on back- up call system on weekends. May interact with clients or customers ranging in age from newborn to geriatric.

Care Coordination:

• Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.
• Coordinate with the interdisciplinary team to develop, revise, (if necessary due to change in patient progress), and implement appropriate discharge interventions to ensure safety and care coordination.
• Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge to including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care on identified high risk patients.
• Communicate with CRM manager any pertinent findings causing a delay in care coordination, safe d/c planning, and/or LOS.

Assessment:

• Completes 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.
• Identifies barriers to health care both in social and medical need that focuses on the prevention of readmissions.
• Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
• Provide and review the appropriate community resources/services with the patient/family.
• Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.

Rounds: (Patient Model of Care, Palliative Care, and long-stay rounds)

• Actively participate in rounds to ensure continuity of care is communicated with other disciplines and to ensure a reduction in LOS.
• Have knowledge of patient plan of care.
• Document appropriately.
• Report patterns of noncompliance.
• Consults regularly with the inpatient provider, PCP, Director and Supervisor, and other team members to ensure that the transition plan remains relevant, appropriate, and responsive to changing patient status and/or goal
• Establish an effective and appropriate means of communicating and collaborating with physicians, team members, payers and administrators to ensure safe and efficient services.
• Identify need for, arrange, and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and medical and/or social issues.
• Develops and maintains collaborative relationships with the post-acute representatives to ensure safe and confidential and transfer is timely.
• Participates in identifying and achieving the departments PI initiatives and goals. Reports and documents process and safety issues in the Events Tracking system.
• Orients new team members and students.
• Maintain professional development best practices and continuing education for care coordination.
• Assist with special projects and other duties as assigned