Clinical Liaison - VBE

Company:

Ascension at Home Together with Compassus

 

Position Summary

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 dis