Summary :

The Care Transition Specialist develops a resource database, coordinates discharge resources per patient, arranges appointments and assists in facilitating treatment through communications to other disciplines and external agencies.

The Care Transition Specialist performs all duties as directed by the Manger of Social Services.

Job Duties & Responsibilities :

Assess patient / family needs for resources based on :

• medication management (psychiatry)
• psychotherapy (individual, group, partial hospital, intensive outpatient, residential)
• ongoing medical care
• housing, placement (nursing home, assisted living)
• financial (application for social security disability, HUD, food stamps, energy assistance, etc.)
• community support (groups)
• specific county-based resources (SAIL, CSP, group home).

Provide Social Services staff with viable resources based on patient need.

• Solicit direction from Social Services staff to meet the aftercare needs of patients.
• Work with the patient care specialists to determine resources based on patient's access to resources and establish a database of resources by payer class.
• Work with Social Services staff to ensure appropriate discharge resources.

Arrange for appointments with aftercare agencies according to social worker direction.

Document calls / results in the EHR under appropriate 'contacts' flow sheets.

Assist in facilitating treatment by acting as a communication resource to other disciplines and external agencies, as directed by Social Services staff, as appropriate.

Complete consents for release of information.

Populate referent / provider database in the EHR, to include :

• nursing homes, assisted living facilities, and hospice care
• outpatient clinics
• long-term care facilities (CBRF and residential)
• psychiatrists (by population served)
• county services
• community support programs
• resources for food, housing, shelters, and financial assistance
• school resources for adults
• school resources for children / adolescents, including alternative schools
• foster care agencies
• in-home treatment providers.

Gain input from Social Services, Community Outreach, Marketing and Admissions departments.

Complete all documentation within the required timeframes.

Complete discharge documentation and Depart Plan, as required, in a timely fashion.

Communicate professionally and accurately.

• Refer to and work with other departments and agencies as needed and according to Social Services policies and procedures.
• Immediately communicate difficult problems with referents, patients, family members / significant others and co-workers to the social worker and / or manager of Social Services, as appropriate.
• Ask for supervision to assist with problem resolution, when appropriate.
• Attend and participate in department meetings as directed by the manager of Social Services.

Demonstrate a strong, interdisciplinary approach, facilitating effective communication among departments.

• Display a positive attitude and participate as a team member.
• Communicate in a respectful and assertive manner to treatment team members and to other Hospital personnel.
• Follow through with program philosophy.

Be professional.

• Arrive on time, prepared for work responsibilities.
• Adhere to the Hospital's dress code.
• Adhere to the Social Work Code of Ethics and the Clinical Code of Conduct.
• Maintain patient confidentiality.
• Implement department policies and procedures.
• Attend and / or plan in-services, Hospital meetings and workshops to keep current on social work issues, techniques, and research.
• Comply with age-specific, mandatory in-services;
• Attend all mandatory in-services;
• Attend clinical workshops / in-services appropriate to the position to maintain competency;
• Assist with the development and facilitation of education / training programs, emphasizing patient care and treatment for all clinical staff, when necessary.
• Serve as a customer service representative in all dealings with patients, family members, significant others, referents, physicians, and others.
• Display respect toward each individual.
• Assist patients, family members and significant others by providing information related to individual need and programming.
• Use a positive, team approach.

Assist with marketing activities in conjunction with Rogers Memorial Hospital (RMH) Community Outreach staff and manager, as requested.

• Provide clinical program information to patients, family members, significant others and / or referents, as appropriate.
• Refer external requests for RMH services to the appropriate Outreach staff.
• Follow-up with referents to affirm potential patient referrals' awareness of various services provided at RMH (residential programs, partial hospitals).
• Solicit feedback from referral sources concerning improving services.
• Solicit feedback from referral sources concerning patient's treatment status.
• Contact identified referral sources to provide update on patient's clinical status.
• Involve self actively with customer feedback.
• Assist Community Outreach with daily activities as requested and as appropriate.
• Assist with facility tours, as needed.
• Accompany Community Outreach staff on site visits with potential referents.

Support Hospital and department performance improvement.

• Assist with performance improvement activities.
• Demonstrate understanding of performance improvement and its role at RM o
• Identify new issues to be included in the performance improvement monitoring activities.
• Communicate with all relevant referral sources on each admission.
• Promote RMH services.
• Advocate improvement of services based on referent feedback.

Provide for patient safety.

• Evaluate patients and communicate to staff observed safety issues to anticipate clinical concerns.
• Intervene appropriately to maintain patient safety.
• Use knowledge of indicators of potentially harmful behavior.
• Use awareness of each patient's level of safety.
• Ensure patients are in appropriate areas at all times.
• Ensure patients use the sign-out / sign-in system when off the unit or as required by program guidelines.

Provide for the safety of the facility.

• Be aware of and understand the Hospital's safety program.
• Report any safety hazards promptly to the manager of Environmental Services or Social Services.
• Use material, safety, and data sheets to document safety issues.
• Initiate Maintenance Requests, as needed.
• Adhere to all Hospital guidelines for safety.
• Maintain updated knowledge of policies and procedures for emergency protocol.

Promote department goals and the mission of the Hospital.

• Communicate goals to fellow staff members.
• Demonstrate measurable goal achievement.
• Maintain department policies and procedures.
• Include requirements and guidelines from external agencies (Joint Commission and State of Wisconsin).
• Maintain and / or communicate the function backlog to the appropriate party at a set time.
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed.

Demonstrate understanding of Joint Commission and other regulatory agency compliance regulations.

• Involve self in the learning and application of standards relevant to the Social Services department.
• Participate in in-services / seminars and other meetings to increase involvement and awareness of regulations.
• Involve self in the education of other disciplines regarding Social Services regulations.

Participate in Hospital committees, Performance Improvement team meetings and team projects, as directed.

• Demonstrate punctuality and preparedness.
• Demonstrate effective communication and organizational skills.
• Contribute in a positive, solution-focused manner.

Participate in the Performance Improvement (PI) program.

• Gain understanding of the PI process.
• Apply the PI model to your department's activities.
• Participate in and / or create PI teams that lead to improvement in other Hospital areas.
• Educate and involve self in the Hospital and Social Service's PI plans.

Conduct self in a professional manner.

• Communicate with all individuals in a positive and professional manner.
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution.
• Communicate concerns and provide solutions for same.
• Attend outside seminars to promote professional growth.
• Demonstrate a positive and professional attitude toward parties outside the Hospital (patients' families, visitors, vendors, etc.).
• Comply with the Hospital's policies and procedures, including Human Resources, Infection Control, and Employee Health policies and programs.
• Project a professional image by wearing appropriate, professional attire.

Additional Job Description :

Physical / Mental Demands :

• Position involves exposure to aggressive / combative patients; must be able to successfully complete aggression control training.
• Verbal and hearing ability is required to interact with patients and employees. Numerical ability is required to maintain records and operate a computer.
• Ability to plan, control and direct all aspects of employee relations. Tact is required to deal effectively with employees and professional staff.

Logical thinking and discretion are required to make decisions in initiating and implementing policies and procedures and standards.

• Must be able to read and communicate through written, verbal and auditory skills and abilities.
• Be physically / mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical.

Education / Training Requirements :

• Bachelor's Degree in Social Work, or related field, from an accredited school of social work or related field.
• Minimum two (2) years' experience in case coordination and discharge planning.
• A Certified Social Worker (CSW) certification, as appropriate.
• Current American Heart Association CPR certification or American Red Cross Professional Rescue is required within thirty (30) days of date of hire.

Bi-annual re-certification is required.

Formal training in the management of the aggressive patient (S.A.F.E.) is required within sixty (60) days of date of hire.

Annual re-certification is required.

Last updated : 2024-04-30