Social Worker Clinical Liaison - VBE

Company:

Ascension at Home together with Compassus

Social Worker highly preferred for this role. Role will cover Seton Medical Center.

The Clinical Liaison is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. This position represents Compassus JV Agencies at contracted JV Partner facilities and requires strong communication and interpersonal skills. The role of the Clinical Liaison - VBE is to coordinate and arrange home care services between the JV Partner hospital facilities and the JV Agencies for home health and hospice, and other community providers when specifically requested by the patients. The position acts as a clinical resource and educates hospital staff regarding the services offered by JV, and enhances the patient care plan as it relates to the discharge plan. The Clinical Liaison - VBE provides information to ensure a smooth transition for patients and their families following hospitalization. The Clinical Liaison- VBE may be assessed for success of achieving Value-Based Enterprise measures.

Position Specific Responsibilities

• • The job duties listed are essential functions of the position. However, other duties may be assigned, and may also be considered essential functions of the position.
  
  
  • The caregiver must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending upon the nature of the position.
  
  
  • For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served.
  
  
  • Assesses referrals for appropriateness for home care and hospice to include medical, physical, social, and emotional status, home environment and family's acceptance and ability to care for the patient in the home and determine the need for equipment.
  
  
  • Coordinates discharge planning for hospital inpatients to home health and hospice service needs of referral sources including physicians and authorized mid-level practitioners (e.g., ARNP or PA) including but not limited to those who are hospital-based, work in clinics, physician offices or elsewhere in the community.
  
  
  • Provides home care information/education at meetings with hospital service, utilization review/discharge planners/case managers, patients and patient's families and educates hospital medical and physician/mid-level staff, patients, and patient's families to available home care services.
  
  
  • Acts as liaison between patients, families, payors, physicians, discharge planners, and the network providing complete physicians' orders, referral information to the network intake department .
  
  
  • Assumes initial responsibility with Hospital discharge planning team for assessing patient/family needs for Home Health, Hospice and consults with the attending physician, Hospice Medical Director, intake team and other staff members as necessary.
  
  
  • Plans for admission of patients to Home Health, Hospice in coordination with agency representative, patient/family, Hospitalist and primary physicians/attendings, Medical Directors and hospital case manager/discharge planner.
  
  
  • Contributes to the clinical determination of a patient's appropriateness for Home Health and Hospice services consistent with applicable policies and admission criteria and in conjunction with patient's physician or appropriate mid-level practitioner.
  
  
  • Facilitates transition of patient/family to primary nurse and other members of the hospice Interdisciplinary Group (IDG) as indicated for patients who elect hospice after determined to be hospice eligible.
  
  
  • Attends appropriate meetings to promote Home Health and Hospice referrals as appropriate.
  
  
  • Maintains and builds existing relationships with post-acute care providers by serving as a resource for education and information.
  
  
  • Evaluates referrals received on hospitalized patient from a variety of care settings for appropriateness for Home Health and/or Hospice [or other in-home services programs as appropriate].
  
  
  • Coordinates with the Inpatient Hospital Team and primary RN/MSW to ensure discharge planning is comprehensive and communicated efficiently.
  
  
  • Appropriately documents activities in the hospital and JV’s electronic medical system; tracks referrals received by nursing unit and accepted by each JV agency.
  
  
  • Actively participates in development and execution of strategic initiatives that include increased Value Based Enterprise care coordination and discharge planning services for applicable post-acute care patients who will receive home health or hospice care following the hospital inpatient discharge.
  
  
  • Attends scheduled meetings and engages in appropriate oversight communications with the Clinical Excellence Team.
  
  
  • Assists patients/representatives complete and obtain Hospice Election Statements and hospice consents.
  
  
  • Assists patient/representatives complete and obtain home health agency consents.
  
  
  • Assists physicians/mid-level practitioner with the admission of patients onto Hospice services as appropriate, though only physicians may certify a patient is terminally ill and eligible for hospice.
  
  
  • Discharges hospice GIP patients receiving care at the Hospital to home/SNF/Assisted Living Facility (ALF) as appropriate, in coordination with the JV hospice’s care team.
  
  
  • Provides staff and physicians with education regarding end-of life care and hospice.
  
  
  • For routine home care hospice referrals, takes hospice evaluation and admission order and ensures appropriate staff, including Care Transition Associates, are notified to follow up that all services and products are arranged.
  
  
  • Follows up with referrals to confirm all services and products have been arranged.
  
  
  • All employees who have contact with participants/residents/ patients/clients are expected to promote the Patients' Bill of Rights and Responsibilities and understand basic procedures for receiving and documenting grievances in order to initiate the appropriate process for participant concerns.
  
  
  • Acquire current knowledge of multiple managed care contracts and network provider subcontracts.
  
  
  • Work cooperatively with Hospital discharge planning team to identify patients who would benefit from homebased care and to effectuate efficient and effective discharges in cooperation with patient's physician/mid-level provider.

Education and/or Experience

• Required - Education sufficient for clinical licensure for discipline (e.g., LPN LVN, Registered Dietitian) Or Required - Bachelor's Degree Social Work

• Preferred - Master's Degree Social Work

• Preferred - Bachelor's Degree Applicable clinical discipline (e.g., Respiratory Therapy).

• Required 1 year Full-time experience in clinical role

• Preferred Liaison, care coordination experience.

• Preferred Health care industry experience.

• Preferred HomeCare HomeBase EMR experience.

• Preferred hospital EMR experience.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.

• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Ability to communicate clearly, sensitively and in a supportive professional manner with patient/family/caregivers, co-workers and public. Strong written and verbal communications in English and excellent customer service communication skills by phone, email, and face-to-face.

• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces integrated healthcare at home philosophy. Understands the purpose and function of Value-Based Enterprise agreement between JV partner and JV for home health and hospice care coordination. Ability to maintain positive, collaborative, and constructive interpersonal relationships. Understands and practices the principles of effective teamwork. Strong skills in prioritizing multiple tasks, facilitating complex problem solving and the ability to work with families/representatives in crisis. Ability to follow appropriate communications channels and excellent negotiation and public relations skills. Demonstrates the ability to remain calm under pressure and adapt to an ambiguous and changing environment.

Certifications, Licenses, and Registrations

• Required upon hire: Current state professional license or certification appropriate to discipline.

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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