Position Summary / Career Interest:

Primary role is to collaborate, communicate and facilitate coordination of services of home health or hospice patient. Responsible for the assessments of patient for post hospital discharge needs including home care, referrals to other medical care providers, nursing home placement, durable medical equipment, and other community resources. The individual in this position functions under the direction of the Manager of Home Hospice.

Responsibilities:

• Complete psychosocial assessment on patients/family/support situations including social, psychological, emotional, financial, and other relevant factors to facilitate discharge planning.
• Initiate timely plan for plan of care and modify plan as needs are identified and resources are determined.
• Participate in daily multidisciplinary health care team meeting, provide relevant information in relationship to patient discharge readiness, options, and services. Identify actual and potential challenges and facilitate interventions to mitigate barriers to successful implementation of discharge plans.
• Maintain regular contact with patients, families, and caregivers regarding anticipated needs, plans, date, treatment options, resources, and assistance, etc.
• Advocate on behalf of patients, families and caregivers’ access to services; assist in navigating complex social systems.
• Maintain current knowledge of available post hospital resources; and maintain adequate supply of resource materials for patients, families, and caregivers.
• Educate patients, families and caregivers on effective ways to mobilize existing resources.
• Complete all required choice forms, discharge notices, etc., per regulations.
• Provide education to patients, families, caregivers on Kansas Advance Directives.
• Ensure pertinent medical information at time of discharge is provided to receiving providers to affect a smooth transition/continuity of care.
• Complete reports to Protection Report Center on suspected patient abuse, neglect, and or exploitation.
• Demonstrate flexibility and teamwork, assist staff in the event of fluctuating census, patient emergencies, etc.
• Plan daily routine to properly organize tasks and demonstrate willingness to meet immediate patient needs effectively and efficiently.
• Supports the financial viability of the hospital utilizing established procedure and appropriate resources to expedite safe and timely discharges.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhausted list of all responsibilities.

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.