Employment Type:

Full time

Shift:

Day Shift

Description:

POSITION PURPOSE

Assists patients and families in coping with problems associated with severe and long-term illnesses.  Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources.  Responsible for coordinating the health care plan (including discharge plans from the acute setting and transitions of care to the post-acute care network) for assigned patient populations through the use of care plans, critical pathways, managed care and collaboration with all members of the health care team.  Evaluates care based upon quality, access, and cost-effectiveness.  Maintains the continuum of care through the coordination and integration of all phases of patient care.  Provides consultation to patient treatment team members and participates in developing new patient care programs.  In various SJMH settings, may provide individual, family, and/or group treatment as part of interdisciplinary treatment plan.  Provides quality patient care considering age specific, developmental, cultural, and spiritual, diversity, and/or other special needs or circumstances through competent clinical practices. 

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Functions as a member of the interdisciplinary care management team.

• Interviews patients and families to obtain psychosocial data. Evaluates and gather data from the patient, family, outpatient supports and other collateral sources (including the primary care provider) regarding plan of treatment and available resources, and develops an appropriate intervention plan.

• Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.

• Coordinates care of identified high-risk patient population across continuum, among others addressing psychosocial issues.  In collaboration with patient, family a primary care provider, develops plan to address and manage issues which influence health care utilization including services for home as well as facilitates hospital-to-hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement.  

• Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow up, and other support services.

• Conducts continuity of care planning for assessing needs and support services for home, as well as facilitates hospital to hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement.  

• Accountability for discharge planning/continuing care needs for assigned populations, including: Assesses, develops, and implements continuing care plans based on identification of patient's health self-care, knowledge, and /or social support system deficits. Conducts ongoing assessment and interdisciplinary collaboration regarding continuing care needs through the continuum. Applies expertise regarding Service Provider Criteria, Insurance Coverage criteria and identification of patient needs. Collaborates with interdisciplinary team regarding patient progress towards expected outcome and revisions to plan of care. Initiates referrals to other providers and disciplines (i.e. Infectious Diseases, Risk Management) as indicated. Refers to Skilled Home Care, Durable Medical Equipment vendors and other appropriate referral sources to assist patient in achieving a safe, optimal continuing care plan. Collaborates with patient/family to ensure appropriate continuity of care arrangements and agency/vendor.

• Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response and maintains good working relationships with community resources.  Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.

• Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end of life decisions, guardianship, etc.

• Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem solving to find solutions.

• Documents soc