JASA’s Care Transitions Specialist (CTS) will coordinate, screen and facilitate the provision of home and community based support services to improve hospital to home care transitions to avoid preventable 30-day readmissions and other preventable hospitalizations. The CTS, an International Medical Graduate, must be bilingual (English/Polish) and have the capacity to work across home, community and clinical settings, including in-hospital.
The CTS must be available to meet patients/caregivers and the hospital discharge team on-site to enable a warm hand-off. The Care Transitions Specialist also will conduct in-home assessments with the following objectives:
Develop community-based service plan
Identify home-based issues that may be linked to readmission risk
Provide direct services and referrals to support stable home based functioning, focusing on:
Medication/DME (other supplies): Ensure patient has medication, supplies and equipment and understands prescribed use
Patient Education: Ensure patient is aware of their health conditions and how to manage them, and understands red flags and health risks
Health Care Provider Communication and Coordination: Ensure patient has a primary care provider (PCP), update PCP on patient status, assist patients with follow up appointments
Screen for and identify social and mental health needs of patients and provide closed-loop referrals
This position will be responsible for:
The provision of In-Hospital (or other clinical setting), In-Home and In-Office Assessment of the social and emotional needs of the older adult client and their family, utilizing prescribed standardized assessment instruments; securing where appropriate the assistance of other social work and/or other professional consultants.
The development and implementation of a case plan for the provision of the full range of social services for the older adult client(s) and family, including:
Education and support to improve disease self-management and prevent avoidable hospital use
Screening of client eligibility, application for, and advocacy in securing benefits and entitlements
The arrangement for direct provision of services such as transportation, homecare services, meals on wheels, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, vocational placement, medical and psychiatric examination and therapy, housing, etc.
Referral, development of relationships and cooperative work with other community agencies, to meet the needs of clients
Informing supervisors of situations of crisis or circumstances where the worker requires further guidance.
Participating in training and team meetings.
Collecting and inputting patient data into JASA’s Electronic Health Record system and assisting with analytics, reports and statistics, utilizing computers.
Performs such other duties as assigned.
International Medical Graduate or equivalent.
Good writing/record keeping skills.
Ability to read, write, speak, understand English.
Ability to read, write, speak, understand Polish.
Must be computer literate, including ability to learn and use program-specific software.
Ability to travel to clients' homes using mass transit and to negotiate any steps and barriers in clients' residences.
Hospital discharge planning or other health care experience preferred.
Understanding and appreciation of the roles of race, religion, ethnicity, sexual preference, and individual values as they relate to serving clients and families.