Community Liaison

Position Summary:

Responsible for the coordination and implementation of case management strategies pursuant to the continuous care from outpatient admission and following discharge. Assisting patients and family members in monitoring follow-up care. To serve as a member of interdisciplinary team supporting the organization's treatment program and philosophy and assure the deliverance of quality treatment to patients and their families. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patients through communication with Physicians and Nurse Practitioners, hospital departments, and community services. Attends treatment team meetings as scheduled. Responsible for New Castle County Territory

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Initiates outpatient program orientation with patient to discuss plan of care
• Monitors cases while in outpatient.
• Coordinates with community resources to ensure continuous care following discharge from program.
• Assist the patient and family members in navigating community resources following discharge.
• Provides initial and ongoing updates and communication to schools and others involved in the patient’s care a minimum of at admission, discharge and once every 2 weeks.  Some patients or contacts may require more frequent communication.
• Assists in coordination of step downs from inpatient hospitalization.
• Provides groups as appropriate for the program.
• Evaluates patient care plans on a regular basis and updates the care plans when needed.
• Faxes aftercare plans to referrals within 24 hours of discharge.
• Will assist in UM process as appropriate.
• Will contact patients to encourage participation in programming.
• Will obtain consents and other documents as appropriate.
• Plans patient care in collaboration with all members of the healthcare team.
• Consults with other departments, as appropriate, to collaborate in patient care and performance improvement activities. 
• Collaborates with other departments to identify operational problems and develop solutions/resolution.
• Works with all members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient.
• Works closely with therapist to integrate psychosocial management of patient/family needs.
• Attends treatment team, coordinates care plan with patient, provider, therapist and RN.
• Initial discharge plan formulated and noted on psychosocial assessment form within 72 hours of admission
• Participates in education on and implementation of clinical guidelines and protocols.
• Documentation meets current standards and policies.
• Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.
• Demonstrates an ability to be flexible, organized and funct