Caseworker/Social Worker (Care Transition Coach)

Mô tả công việc

Caseworker/Social Worker (Care Transition Coach) This position will provide support for the smooth transfer of patients from hospital to home and direct linkage to community based services. Responsibilities include: Provide Care Transition Services, utilizing the Coleman Transition Model, to assigned patients who are being discharged from partner hospitals, using  assigned screening tools Provide in-patient, home visitation, and follow up telephonic care transition services Establish and maintain positive working relationships with hospital discharge and nursing staff Establish and maintain positive working relationships with primary care physicians Provide Problem Solving Therapy (PST) for clients and caregivers, as indicated Maintain accurate and professional documentation and data collection using mandated data base Provide connections and linkages to community based services Entering patient and service data into appropriate databases Arranging and coordinating follow up care services for clients according to the plan of care Liaison with hospital staff around data and reporting issues Maintaining files and other clerical support as necessary Weekend work required Other related duties as assigned