Job Summary
The responsibility of the LMSW - Transitional Case Manager is to work with SHP patients and their families to assure a smooth transition following the discharge from the hospital. This position works collaboratively with the SHP Chief Medical Officer, HH providers, hospitals based specialists, HH 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.

The LMSW - Transitional Case Manager will facilitate the patient's progression throughout the care continuum and stabilize the transitional periods. The LMSW - Transitional Case Manager identifies and monitors patients with complex disease states and provides patient/family education and direction. Working with the PCP or specialist, the LMSW - Transitional Care Coordinator assists in the coordination of medical services and with transitions between levels of care and makes appropriate referrals for community services for the patient and family/caregivers. The LMSW - Transitional Care Coordinator provides patient care in accordance with acceptable nursing practice, legal and regulatory requirements, and ethical considerations following facility policies and procedures.

The LMSW- Transitional Care Coordinator participates in data collection and analysis to support care management outcomes and identify performance improvement opportunities.

The LMSW- Transitional Care Coordinator acts as a patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication. As a patient advocate, the LMSW- Transitional Care Coordinator also monitors patient care to ensure that the patient receives quality care through the use of standards of care and evidence based practice guidelines.

• 1.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.
  
• Communicates cases to supervisor for transition to the appropriate level of acuity case management team. Provides effective communication of plan of care between the PCP and specialists involved in the patient's care.
  
• 2.Facilitates a smooth and timely care for high risk patients in the outpatient setting.
  
• Coordinates follow-up care with PCP/ Specialists regarding outpatient follow-up appointment and plan of care. Coordinates care with internal and external providers and healthcare team members involved in the care.
  
• Communicates key information regarding to patient's PCP and healthcare team.
  
• Ensures safe transmission of personal health information.
  
• Ensures post-acute telephone, home visits are conducted and after care issues are followed-up as determined by case needs.
  
• Provides psychosocial assessment, crisis intervention and supportive services for identified patients, families and staff.
  
• Assess behavioral health needs including depression screening, suicidal risk, etc.
  
• Assesses, intervenes and reports domestic violence, abuse and other reportable situations in accordance with legal mandates.
  
• 3.Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served through the continuum of care. Establishes professional relationships with acute and post-acute colleagues.
  
• 4.Communicates effectively and professionally using all modalities i.e. Technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise.
  
• 5.Performs active listening, uses motivation interviewing and open ended questioning techniques and guided care goal setting for the patient working respectfully and creatively with patients of diverse functional abilities, social, economic, and cultural backgrounds - supporting both patient autonomy and safety. Is assertive and creative in problem solving, skilled in negotiation and conflict resolution.
  
• 6.Maintains all regulatory educational requirements participating in continuing education and quality improvement activities. Demonstrates professional behavior and promotes cooperation and team building
  
• 7.Demonstrates technical skill and new forms of technology in maintaining clear and professional clinical documentation in software data base for cases followed under transition and for case assignment.
  
• 8.Maintains and manages to their caseload working independently with a minimum of direction, anticipate and organize workflow, work with a high volume caseload, deal effectively with rapidly changing priorities and follow through on responsibilities.
  
• 9.Interprets data and analyze trends and make decisions based on best clinical judgment and current practice standards for specific disease states. Have knowledge of chronic illnesses and their physical and psychosocial effects on the individual through the continuum.
  
• 10.Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served
  
• 11.Have knowledge of applicable laws and regulations, government (Medicare, Medicaid, SSI, and SSDI) and insurance benefits. Maintain current knowledge of new regulations on federal, state and local levels as well as practice guidelines and standards of practice.
  
• 12.Maintains all regulatory educational requirements participating in continuing education and quality improvement activities. Demonstrates professional behavior and promotes cooperation and team building. Effective as a team member and leader