DUTIES: - Coordinate and reinforced discharge summary with patients. - Coordinate all services available to patients, (established and new). - Assist in linking to primary care and other outpatient care providers. - Confirm that patient has documented PCP on file and if not assist patients with assignment of the PCP. - Ensuring that patients discharge with primary care appointment within 7 days from discharge (appointments back to PCP or to Transition Care Clinic, TCC). - Development of care plans for all at-risk patients prior to inpatient discharge. - Coordination of all existing services. - Maintain regular communication with community providers (e.g. home care, community pharmacy) to coordinate as needed. - Identify social determinants of health (SDOH) that could affect a patient's ability to transition safely to the community and arrange for needed services (i.e., nutrition, transportation, caregiver support, medication coverage, medical supplies, etc.). - Provide self-management support to patients. - Link to community-based resources as needed, e.g., home services, nutrition, social services, caregiver support). - Ensure ability to obtain medications, medical equipment, and other supplies as prescribed. - Call patient after discharge within 24-48 hours or as needed to coordinate careplan needs. - Document in patients' care plan in established care management systems a minimum of weekly or as needed. - Conduct follow-up contact (face to face visit or phone calls) based on patient's needs within 72 hours of hospital discharge. - Provide at least one contact weekly or needed for the 30 day period (phone or face to face by SW or Community Liaison). - Conduct a case conference within 24 to 48 hours following any critical events. - Enter data, create care plan, and track in establish care management system. - All data/encounters should be entered immediately or no later than 24 hours after interaction with patients. - Ensure that all cases or follow through and closed appropriately as per patient's status. - Identification and case review of patients who are likely to be admitted and, when appropriate, development of community-based alternatives to admission. - Completion of follow-up phone calls or home visits for all enrolled patients during the 30-day intervention period. - Communication and follow-up support for linkage to primary care and home care. - Referral to Supervisor of all A.C.S. cases referred during the tour for follow up. - Psychosocial assessment for at risk patients being discharged and high risk patients being admitted (psychosocial to include awareness of patients' mental and ADL status, home environment, previous home care services, significant others etc.). - Work closely with team members and all hospital personnel to prevent avoidable admissions, readmissions and to transfer patients to inpatient psychiatric facility as indicated. (DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION) QUALIFICATIONS: - New York State Licensed Social Worker (LCSW, LMSW). - Master's Degree in Social Science. - A minimum of three (3) years of social work experience. - A minimum of two (2) years of discharge planning. - Knowledge of Federal, State and TJC regulations. - Knowledge of Medicare, Medicaid and Managed Care. Additional Info: *Please ensure you include the 5-digit Line Number and Job Title in the subject line and body of your email submission.Closing Date: Open Until Filled STATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Internal Number: 52795
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.