Lmsw Social Worker Transitional Care Management - Scottsdale, United States - HonorHealth

HonorHealth
HonorHealth
Verified Company
Scottsdale, United States

3 weeks ago

Mark Lane

Posted by:

Mark Lane

beBee recruiter
Description

Overview:

Looking to be part of something more meaningful? At HonorHealth, you'll be part of a team, creating a multi-dimensional care experience for our patients.

You'll have opportunities to make a difference.

From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact.

Join us. Let's go beyond expectations and transform healthcare together.

Master's Degree in Social Work Required

Experience

1 year of progressively responsible and directly related work experience in a healthcare setting required. Required

1 year LMSW Required

Other Social Work Required

Other Acute or Post-acute or community setting Required

Licenses and Certifications

Basic Life Support (BLS) BLS-C Upon Hire Required

LMSW or LCSW Upon Hire Required


Responsibilities
:
Job Summary


The responsibility of the LMSW - Transitional Case Manager is to work with ICP patients and their families to assure a smooth transition following the discharge from the hospital.

This position works collaboratively with the ICP Chief Medical Officer, HH providers, hospitals based specialists, HH case Managers, the Comprehensive care coordinators, post-acute facilities care coordinators, and other agencies as needed to create a smooth transition following discharge from either an acute care setting or post-acute setting.

The LMSW - Transitional Case Manager collaborates with the primary physician and other health care team members in the development of the patient goals and action plan, ensuring the formulation of a realistic and definitive transitional care plans that represents the total care needs and resources of the patient/client and family.


The LMSW - Transitional Case Manager will facilitate the patient's progression throughout the care continuum and stabilize the transitional periods.

The LMSW - Transitional Case Manager identifies and monitors patients with complex disease states and provides patient/family education and direction.

Working with the PCP or specialist, the LMSW - Transitional Care Coordinator assists in the coordination of medical services and with transitions between levels of care and makes appropriate referrals for community services for the patient and family/caregivers.

The LMSW - Transitional Care Coordinator provides patient care in accordance with acceptable nursing practice, legal and regulatory requirements, and ethical considerations following facility policies and procedures.


The LMSW- Transitional Care Coordinator participates in data collection and analysis to support care management outcomes and identify performance improvement opportunities.


The LMSW- Transitional Care Coordinator acts as a patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication.

As a patient advocate, the LMSW- Transitional Care Coordinator also monitors patient care to ensure that the patient receives quality care through the use of standards of care and evidence based practice guidelines.


  • Collaborates with patients/caregivers to ensure care is coordinated across the health care continuum involving acute and postacute transitions as well as stabilization back in the home when appropriate.

Key areas of focus include:
Establish relationship with patient/caregiver.

Supports and coordinates with patient, family and inpatient multi-disciplinary team members providing appropriate pathway, screenings, assessments, care coordination, advance directives, early & post-acute interventions, readmission risk, barriers to care outpatient including home support, medication management, and home safety.

Provides support and guidance to patients and their caregivers regarding medication reconciliation, assessment of post-discharge home care needs, self-management support, follow-up care, supportive care, end-of-life decisions, community resources, and long-term planning needs.

Assures PCP is aware of patient's status and needs.
Review patient assessments including education required due to new medications/changes to medication regimen, disease specific "red flags" of complications

Conduct or arrange for effective home visits, telephonic monitoring, or both depending on the tier level of each case and risk for readmission or ER visit.

Communicates cases to supervisor for transition to the appropriate level of acuity case management team. Provides effective communication of plan of care between the PCP and specialists involved in the patient's care.

  • Facilitates a smooth and timely care for high risk patients in the outpatient setting.
Coordinates follow-up care with PCP/ Specialists regarding outpatient follow-up appointment and plan of care. Coordinates care with internal and external providers and healthcare team members involved in the care.
Communicates key information regarding to patient's PCP and healthcare team.
Ensures safe transmission of personal health information.
Ensures pos
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