Care Coordinator, Transitions of Care - IL (Chicago)

#communityhealth #healthcare

About Us:

Cityblock Health is the first tech-driven provider for communities with complex needs—bringing better care to where it’s needed most, block by block. Founded in 2017 on the premise that “health is local” and based in Brooklyn, we are backed by Alphabet’s Sidewalk Labs along with some of the top healthcare investors in the country.

Our mission is to improve the health of underserved communities. Importantly, our solutions are designed specifically for Medicaid and lower-income Medicare beneficiaries, and we meet our members where they are, bringing care into the home and neighborhoods through our community-based care teams and Virtual Care offerings.

In close collaboration with community-based organizations, local providers, and leading health plans, we are reorganizing the health system to focus on what matters to our members. Equipped with world-class, custom care delivery technology, we deliver personalized primary care, behavioral health, and social services to deliver a radically better experience of care for every member and community we serve.

Over the next year, we’ll grow quickly to bring better care to many more members and their communities. To do this, we need people who, like us, believe that everyone should have good care for what matters to them, in their community. 

Our work is grounded in a belief in the power of a diverse community. To close gaps in care and advance equity in the communities we serve, we have to start with making our own team diverse and inclusive. Our ways of working are characterized by creativity, collaboration, and mutual learning that comes from bringing together a community from diverse backgrounds and perspectives. We strive to ensure that every person on the Cityblock team, and every Cityblock member, feels supported and included as a part of our community.

Our Values:

• Aim for Understanding
• Be All In
• Bring Your Whole Self
• Lean Into Discomfort
• Put Members First

About our Team: 

We employ a field-based, home-based care model and are committed to meeting members where they are--in their homes, in their community, and in our Hubs. You will go above and beyond to connect with Cityblock members in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day.

About the Role:

Cityblock’s Transition of Care (TOC) program helps members safely navigate their post-discharge journey from acute care and hospital settings back into the community. As a TOC Care Coordinator,, you will reach out to members to schedule post-discharge visits, provide care coordination and drive engagement to help ensure that members do not return to the hospital.

Essential job responsibilities: 

Engagement

• Receive assignment of members from TOC team
• Reach out to member/caregiver to schedule post-discharge visit; describe the TOC program expectations and goals 

Assessments/Intake

• Complete assessments following protocols and as needed by the TOC Registered Nurse Care Manager (TOC RNCM)

Case Review and Care Planning

• Support  the TOC RNCM during discharge planning 
• Partner with the TOC RNCM to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery
• Support members in achieving their care plan goals
• Bring preliminary goals and identified resources to members to address social and care coordination needs 
• Work with members to address goals in care plans and coach to completion
• Focus on members’ goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs  
• Participate in case conferences upon member discharge to discuss 30-day readmission mitigation plan 
• Collaborate with TOC RNCM for hand-off to longitudinal care at conclusion of the TOC program
• Collaborate with TOC team to determine need for escalation of member care

Follow-up

• Weekly check-ins with members to follow-up on post-discharge care plan needs and progress
• Provide care coordination (e.g., benefits, social needs, external care) with the member/caregiver, internal care team and external providers
• Provide routine non-clinical education on preventative care topics
• Address and respond to member needs and delegate tasks in timely fashion
• Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs
• Complete screenings for emerging needs
• Refers members to the TOC RNCM for clinical needs