Continuing Care Liaison MSW

Dartmouth Health•White River Junction, VT

About The Position

As a Continuing Care Liaison - MSW, you will be an integral member of a multi-disciplinary health care team that provides continuity of care in transitioning complex care patients from the acute care setting to home. This role partners with the acute care setting interdisciplinary team in identifying patient/family needs and developing the plan of care to successfully transition home. You will continue to follow the patient, working with the home-based care interdisciplinary team to ensure health outcomes are met and patient/family success at home.

Requirements

Masters of Social Work required.
Minimum one year of experience in a health-related field required.
Valid driver's license.
Clean driving record.
Current car insurance that meets minimum standards.
BLS certification within 90 days of hire.

Nice To Haves

Collaborative team player.
Use of systems approach in planning, problem-solving, and decision-making.
Creativity, innovation, risk-taking, autonomy, flexibility, receptiveness to change.
Commitment to professional growth.
Understanding of and comfort using computers.
Licensed Independent Clinical Social Worker (LICSW) in New Hampshire and VT, preferred.

Responsibilities

Serve as an integral member of a multi-disciplinary health care team providing skilled nursing, rehabilitative care, and medical social work to patients, enabling them to receive necessary medical care in their own homes.
Accurately document observations, interventions, and evaluations related to patient care management and services.
Collaborate with discharge planners and referring providers to identify high-risk patients and ensure a seamless transition to DHHC services.
Provide information and education to prospective patients and families about home-based care services.
Conduct comprehensive patient/family assessments and, in collaboration with the patient, family, and care partners, develop a plan of care for transitioning the patient from the acute care center to home.
Provide ongoing support and coordination for patients and families after their transition home.
Utilize innovative strategies to advocate for patient needs and negotiate complex systems to remove barriers and limitations in transitioning patients home.
Monitor the patient's transition across and within various care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital).
Share assessment and physical, psychological, social, and environmental care plan data with patient/family consent as the patient moves through different care settings.
Identify gaps in the care continuum and collaborate with community and provider networks to expand access to necessary physical, psychological, social, and environmental services.
Participate in the development, maintenance, and coordination of an interdisciplinary care delivery system tailored to individual patient needs, promoting effective resource utilization.
Collect and evaluate data and outcomes, including patient satisfaction, health and functional status, and resource utilization.