Care Coordinator (LCSW, LMSW or RN) PRN Weekends

JOB PURPOSE & MISSION

Essential Job Functions include, but are not limited to:

1. Facilitates triple aim initiatives by ensuring access to appropriate care.

• Advocate for patients by assessing that patient healthcare needs are being addressed in the most appropriate level of care.
• Understands and works in all hospital settings for patient coordination or care, such as the emergency department, ICU, Burn unit, Women & Infant, med/surg/telemetry, etc.
• Screens patients to determine appropriate level of care coordination interventions based on risk factors related to barriers that impact progression of care, transition of care, and readmissions.
• Assesses patient situation by collecting information from patient and family, professional and non-professional caregivers, employers (as appropriate), and health records to identify individual needs to develop a comprehensive progression-of-care management plan and assessment that will address those needs.
• Confirms admission diagnosis and identifies related quality metrics to promote medical compliance.
• Partners with the medical team to participate in developing a medical treatment plan appropriate to the patient's level of care and preferences.
• Encourages and facilitates patient/family participation in all care and treatment decisions.
• Educates members of the patient's healthcare team on the appropriate access to and use of various levels of care.
• Recognizes and responds appropriately to risk factors.

2. Implements a wholistic and patient-driven approach to care management.

• Assess the effectiveness of services and their outcomes in concert with the interdisciplinary team, recommending appropriate plan modifications to ensure treatment objectives are met.
• Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
• Provide point-of-care coaching to medical documentation that accurately reflects intensity of services, quality and safety indicators, and patients' response to treatment.
• Consults with medical advisors as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
• Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, external case managers, and post-acute providers.
• Facilitate and coordinate patent and family meetings to discuss goals of care, difficult treatment recommendations, new diagnosis, etc.
• Facilitate complex psychosocial assessments and brief counseling on such topics as fetal demise, teen pregnancy, new cancer diagnosis, complex medical treatment needs, wound/burn care, trauma, guardianship, return to home barriers, goals of care, advanced directives, etc. as they impact patients' hospitalization.

3. Orchestrates the coordination of care throughout the patient continuum.

• Serve as a primary liaison between and among physicians, patients, families, payers, external case managers, post-acute providers, and interdisciplinary clinical team.
• Maintain appropriate documentation for each patient to include specific documentation of all planning, liaison, and coordination activities.
• Collaborates with post-acute coordinators to monitor and facilitate the progress of completing discharge logistics.
• Proactively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources.
• Meet with patients and family as appropriate to provide updates on treatment plan, obtain their input and develop realistic, obtainable discharge goals.
• Maintain contact with patient, family, payer, and/or post-acute provider regarding initial assessment, progress, changes in condition, approval for special procedures, equipment, other services, and upcoming discharge.
• Assess, consult, communicate, and facilitate a resolution regarding patient's social service resource needs, anticipated psychosocial issues, negative family dynamics, financial constraints, palliative care, psychological or hospice needs.
• Assess, consult, and communicate with the interdisciplinary team about social determinants of health and risk factors that could impact patients' successful transition and/or potential likelihood for risk of readmission.
• Actively participate in daily huddles, patient care conferences, and hospitalist/nurse hand-off reports to gather sufficient information to determine the effectiveness of the treatment plan and patient care goals.

4. Steward of resource management.

• Identify, organize, and secure the resources necessary to accomplish the goals set forth in the patient's treatment plan.
• Facilitate the timely delivery of services to patients and families through effective management and utilization of available resources.
• Interface with utilization reviewers to stay current on patient's eligibility for admission, continuing stay or readiness for discharge.
• Persevere in attempts to influence clinical and financial outcomes of care.
• Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Understands and applies federal law regarding the use of HINNs, ABNs, Important Message from Medicare (IM), Medicare Outpatient Observation Notice (MOON), and discharge appeal rights.
• Evaluate patient care outcomes to determine the effectiveness of the treatment plans for clinical and financial effectiveness.
• Assertively manage resource utilization while appropriately navigating the patient's movement along the continuum of care.
• Collaborate with attending and hospitalist physicians to influence appropriate utilization of resources and transitions from one level of care to another.

5. Coordinates a safe and timely transition of care for appropriate patients.

• Advocate for the patient to expedite progression of care and ensure appropriate level of care.
• Makes timely referrals to the Post- Acute Resource Center to expedite post-acute service arrangements.
• Collaborate with nursing and members of the clinical team to provide patient/family education regarding discharge goals that require the team's expertise (medication administration, transferring to/from a car, oxygen use, etc.).
• Research discharge placement options, when home discharge is not possible, while continuing to focus on patient/family goals, interdisciplinary team recommendations, available payer benefits and private financial considerations which may impact placement.
• Assure discharge plan is addressed during daily rounds, keeping patient/family objectives in mind while modifying the plan as appropriate and posting on the patient's white board.
• Update all involved parties regarding progress, revisions and other information related to transition readiness.
• Facilitate referrals to local, state, and federal resources and arranging patient/family counseling or support groups after discharge.

6. Provides supervision for nursing students, undergraduates, CSW/LMSW interns as appropriate.

• Mentors' undergraduate and/or nursing students.
• Reviews documentation of CSW/LMSW interns.
• Meets supervision requirements for CSW/LMSWs in accordance with the Louisiana Social Work Practice Act and Louisiana Administrative Code, Title 46, Part XXC.

7. Performs all other duties as assigned.