Continuing Care Liaison Licensed Clinical Social Worker, Full-time

Dartmouth-Hitchcock Health•Hartford, VT

About The Position

The Continuing Care Liaison is an integral member of a multidisciplinary health care team, helping complex-care patients transition from an acute care setting to home. The role partners with acute-care interdisciplinary teams to identify patient and family needs and develop a plan for a successful transition. After the patient returns home, the liaison continues to coordinate with the home-based care team and provide support to help achieve health outcomes and patient and family success. The position is part of Dartmouth Health Home Care, which provides nursing, rehabilitation, hospice, and personal care services across more than 70 towns. The role serves the Upper Valley and surrounding areas and contributes to home-based care that allows patients to receive needed medical services in their homes.

Requirements

Master of Social Work degree.
At least one year of experience in a health-related field.
Hold at least one active, unencumbered LICSW license in Vermont or New Hampshire at the time of hire.
Obtain active, unencumbered LICSW licenses in both Vermont and New Hampshire within 30 days of the hire date.
Valid driver's license and clean driving record.
Current car insurance meeting minimum standards.
BLS certification within 90 days of hire.

Nice To Haves

Collaborative team-player approach.
Use of a systems approach in planning, problem solving, and decision making.
Creativity, innovation, risk-taking, autonomy, flexibility, receptiveness to change, and commitment to professional growth.
Understanding of and comfort using computers.

Responsibilities

Partner with acute-care interdisciplinary teams to identify patient and family needs and develop plans for transitioning complex-care patients from the acute-care setting to home.
Work with discharge planners and referring providers to identify high-risk patients and support a seamless transition to Dartmouth Health Home Care services.
Provide information and education to prospective patients and families about home-based care services.
Perform comprehensive patient and family assessments and develop transition plans in collaboration with patients, families, and care partners.
Provide continuing support and coordination to patients and families after the transition home.
Document observations, interventions, and evaluations related to patient care management and services.
Advocate for patient needs and negotiate complex systems to remove barriers to transitioning patients home.
Monitor patient transitions across and within care settings, including home, clinics, skilled nursing facilities, rehabilitation, and hospitals.
Share assessment and care-plan information concerning physical, psychological, social, and environmental needs with patient and family consent as patients move between care settings.
Identify gaps in the care continuum and work with community and provider networks to expand access to needed services.
Participate in developing, maintaining, and coordinating an interdisciplinary care delivery system tailored to individual patient needs and effective resource utilization.
Collect and evaluate outcomes, including patient satisfaction, health and functional status, and resource utilization.
Perform other related duties as assigned to meet organizational needs.