DUTIES: The Community Liaison Worker will work alongside the Social Worker in carrying out home visits to follow up with patients, ensuring patient self-management, obtaining prescriptions, engaging in healthy living and other activities to obtain and maintain a healthy status. Transition of Care (TOC) Inpatient Community Liaison will work collaboratively with all level of the ED/Inpatient Staff and provide administrative support to the TOC Inpatient Team. The TOC CLW will coordinate with other care management services available to the patient linkage to primary care and other outpatient care providers. 1. Confirm that patient has documented PCP on file and if not assist patients with assignment of the PCP. 2. Ensuring that patients leave the inpatient hospital stay with primary care appointment within 7 days but no later than 30 days and will schedule appointments in appropriate systems as needed. 3. Coordination of all existing services. 4. Maintain regular communication with community providers (e.g. home care, community pharmacy) to coordinate care and ensure all needed care are implemented post discharge. 5. Link to community-based resources as needed e.g., home services, nutrition, social services, caregiver support). 6. Ensure ability to obtain medications, medical equipment, and other supplies as prescribed. 7. Call patient after discharge within 24-48 hours as directed RN and or LMSW/LCSW. 8. Document all interactions with patients in EMR/Care Management System. 9. Provide at least one contact weekly or as needed for the 30-day period (phone or face to face). 10. Participate in all patients' case conferences as needed. 11. All data should be entered immediately or no later than 24 hours after interaction with patients into EMR/Care Management System. 12. Accompany patients, as needed, to medical/mental health appointments. 13. Completion of follow-up phone calls or home visits for all enrolled patients during the 30-day intervention period. 14. Communication and follow-up support for linkage to primary care, Health Home, home care, and other community-based resources, as needed. 15. Ensure that all cases or follow through and closed appropriately as per patient's status. All other tasks assigned by Management Team. (DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION) QUALIFICATIONS: REQUIRED: Bachelor's degree in Social Work with 3+ years' experience. Excellent knowledge of MS Office; excellent communication skills. Very good organization and multi-tasking abilities. PREFERRED: Master's degree. Home visit experience. Experience with inpatient/outpatient Care Management. Additional Info: * Represents Location Pay for full-time appointees. Hours of work: 9AM-5PM; Days of week: Monday-Friday; Hours per week: 37.5Closing Date: Open Until Filled STATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Internal Number: 52416
About SUNY Downstate Medical Center
SUNY Downstate's College of Medicine, Health Related Professions, Nursing and its School of Graduate Studies offer students a broad professional education that will prepare them for practice or careers in any location and community. This education provides exceptional opportunities for those students with a commitment to promoting health in urban communities and addressing the complex challenges of investigating and preventing diseases that confront clinicians, educators, and researchers in such an environment. This special aspect of Downstate's unique mission is reflected in the students it attracts and selects, the vast majority of whom are drawn from the New York City Metropolitan area. Many of these students are members of minority and cultural groups underrepresented in the health professions, and/or come from families of first-generation immigrants or from economically disadvantaged backgrounds.