Care Transition Specialist, Lead - Post Acute Capacity

Care Transition Specialist, Lead / 40 hour Rotation

• BWH Care Coordination

• Post Acute Capacity

GENERAL SUMMARY/OVERVIEW

As a member of the Mass General Brigham

• Care Continuum Management team, the Care Transition Specialist Lead will routinely perform Care Transition Specialist duties in addition to completing and supporting with analytical, administrative, and escalation duties for MGB Post-Acute Capacity and as directed by department administration. The analytical, administrative, and training duties will be balanced with the Care Transition Specialist duties by department administration. The Care Transition Specialist Lead will work with Case Managers, Social Workers, and other care team staff to ensure that patients receive the resources and services they need to successfully return to a community setting, including home with services (i.e. Visiting Nurse Association) or without services, skilled nursing facility, acute rehab, long term acute care facility or outpatient clinic. The Care Transition Specialist Lead is responsible for managing system referrals, escalations and supporting patient progression. The Care Transition Specialist Lead is responsible for acting as an advocate for patients and patient families and strive to support the hospital's aims for optimal resource management, high customer satisfaction, and high quality care.

Patient Care Management:

• Assists with MGB Post-Acute Capacity referrals as directed by the Post-Acute Capacity team

• Proactively facilitates referrals across Mass General Brigham, ordering of equipment (e.g. DME) and medication, completion of forms, and placement from inpatient and outpatient settings.

• Acts as a consultant to the hospital community, patients and families regarding the placement process and access to community resources.

• Establishes homecare plan in conjunction with the CCM and documents the plan and progress in the medical record, including assistance with obtaining medications or DME needed at discharge.

• Coordinates and expedites final transfer with staff, patient, family and facility.

• Updates the staff on new facilities, services, and resources; and maintains a library of reference materials.

Referral Management:

• Coordinates long and short term placements to extended care facilities, e.g. rehabs, sub-acute, etc. Documents discharge plan in electronic referral system or via fax, and monitors, and manages follow-up or escalates, as needed.

• Actively communicates, consults and collaborates with a wide range of social agencies, clinics, schools and courts.

• Plans, when appropriate, a continuation of previous utilization management services and/or agency for continuity of care.

• Interprets insurance coverage and makes recommendations for short term rehab or non-acute options.

• Develops relationships and maintains contact with appropriate facilities and resources. Occasionally visits sites.

Evaluation:

• Monitors quality of care in ECF's, home/community agencies and reports findings to the Program Manager.

• Maintains current information on non-acute provider agencies, including SNF, sub-acute, acute rehab and chronic facilities, including programs, homecare and specialties available. Acts as a resource to staff, patients and families concerning this information.

• Provides follow-up and ongoing assistance with assessing community and ECF services. Follows up and tracks utilization of referred patients for evaluation purposes and provides feedback to the Program Manager.

• Participates in relevant planning meetings to provide input into practice and program needs.

Performance Improvement:

• Maintains a statistical data base on escalations, referrals, admissions and homecare/community agency resources and tracks discharge process utilized by the patient.

• Participates in the development and monitoring of performance standards for extended care facilities and homecare/community agencies. Maintains documentation to support findings.

• Maintains contact with State regulatory agencies and non-acute care provider agencies to keep current on the rules and regulations needed to facilitate discharge planning.

Analysis, Administrative, and Training Duties:

• Analyzes operational data to evaluate performance as directed by department administration

• Supports the documentation of outcomes and ideas generated through task forces and initiatives as it relates to the department's objectives and specifically related to Post-Acute as directed and overseen by department administration

• Meet expectations related to collection and synthesis of relevant data, communication summaries, and tracking of tasks and related outcomes as directed by department administration

• Manage ad hoc projects as directed by department administration

• Facilitate process and technical training for Care Transition Specialists and other department roles as directed by department administration

Working hours:

Tuesday

• Saturday

8:00am to 4:30pm or 8:30am to 5pm

Rotating Hours

Hybrid

• Bachelor's Degree required and health care experience, preferably in extended care facilities and community agencies.

• Required, 3-yr experience in hospital discharge planning, long term care facility, community health or utilization review.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED

• Interpersonal skills to interact effectively with various levels of staff, patients, families and community organizations. Must be able to participate effectively in an interdisciplinary team setting.

• Extensive knowledge of regulations, community organization, state and federal systems, medical terminology and levels of health care.

• Must be able to manage a variable workload with the ability to constantly change priorities. Requires ability to work proactively and independently.

• Requires basic typing and/or computer data entry skills, experience with personal computer and software desirable.

• Must be very flexible in a constantly changing environment.