The responsibility of the LMSW - Transitional Case Manager is to work with patients and their families to assure a smooth transition following the discharge from the hospital. This position works collaboratively with the Chief Medical Officer, providers, hospitals based specialists, 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.
Collaborates with patients/caregivers to ensure care is coordinated across the health care continuum involving acute and post-acute 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.
Master’s Degree in Social Work
LMSW or LCSW Certification
1 year of progressive responsibility and directly related experience in a healthcare setting
3 years LMSW in a case manager or discharge planning role preferred
Internal Number: 1
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