MetroWest Medical Center is the largest community health care system between Worcester and Boston. MetroWest Medical Center is committed to providing high quality, comprehensive care, at a location close to home. The 307-bed regional healthcare system includes Framingham Union Hospital, Leonard Morse Hospital in Natick and the MetroWest Wellness Center. MetroWest Medical Center has been named to the 2019 America�s 100 Best Hospitals List by Healthgrades.
GENERAL SUMMARY: The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient�s resources and right to self-determination. The individual in this position has overall responsibility to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and interventions to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
� Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
� Care Coordination by demonstrating throughput efficiency while assuring care is sequenced and provided at the appropriate level of care
� Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
� Education provided to physicians, patients, families and caregivers
� Participates in planning the social work component required in selected hospital programs
� Provides in-service education for staff
� Collaborate with community providers to develop educational resources appropriate for staff and patients/patient representatives
This individual�s responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely, complete and concise documentation in Tenet Case Management documentation system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Transition Management
� Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
� Integrates key elements of patient assessment, patient preference & choice and available resources to develop and implement a successful transition plan
� Completes Complex/Psycho-social assessment and plan for patients identified as high risk for readmission.
� Provides psycho-social assessment and intervention for patients identified with needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence.
� May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately
� Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
� Provides information to patients to make informed choices per Tenet policy
� Completes Final Discharge Disposition Form for Medicare beneficiaries per Tenet policy
� Completes timely, complete and accurate documentation in the Tenet Case Management documentation system to communicating information to the care team and provide documents needed in the patient record
(40% daily, essential)
2. Care Coordination
� Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
� Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
� Assists with adoption/abuse/neglect cases and reporting of appropriate cases to local, state and/or federal agencies
� Ensures the plan of care is consistent with patient preference & choice and available resources
� Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
� Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimal outcomes
(40% daily, essential)
3. Education
� Ensures and provides education to patients, physicians and the healthcare team relevant to the safe and timely patient transition
� Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
� Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
(10% daily, essential)
4. Compliance
� Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
� Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
� Operates within the Social Work scope of practice as defined by state licensing regulations
(10% daily, essential)
5. Complex Patient Management
� Completes quality and accurate Adult Transition Evaluations
� Completes accurate risk assessments and follow up as coach with other colleagues
� Starts discharge planning and referrals within 1-2 days of admission and escalate any barriers to care to DCM
� Schedules family/patient conferences with physicians, other disciplines at least weekly
� Assist in resolving difficult issues early for example - potential legal and ethical needs or complex medical concerns align with DCM
