Continuing Care Liaison MSW, Full-time

Dartmouth-Hitchcock Health • Hartford, VT

13d • Hybrid

About The Position

The Dartmouth Health Home Care is seeking a Continuing Care Liaison MSW to join their team. This full-time, day shift position offers a unique opportunity to experience satisfying and challenging work that makes a difference every day. You will have the chance to truly get to know your patients, becoming an integral part of their care team. While enjoying broad independence, you will also be part of a cohesive interdisciplinary team. This role allows you to be an important part of the community where you live and offers a work/life balance that can match the flexibility you need. Dartmouth Health Home Care covers more than 70 towns, delivering superior nursing, rehabilitation, hospice, and personal care services with proven effectiveness, integrity, and compassion. Their goal is to help the people in their communities, and joining their team means becoming part of a dedicated group delivering outstanding home health and hospice services that enrich lives.

Requirements

• Masters of Social Work required.
• Minimum one year experience in a health-related field required.
• Valid driver’s license, and a clean driving record
• Current car insurance, which meets minimum standards
• BLS 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 and a commitment to professional growth desired.
• Understanding of and comfort using computers desired.
• Licensed Independent Clinical Social Worker (LICSW) in New Hampshire and VT, preferred.

Responsibilities

• 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.
• Partner with the acute care setting interdisciplinary team in identifying patient/family needs and developing the plan of care to successfully transition home.
• 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.
• Provide skilled nursing, rehabilitative care, and medical social work to patients, allowing them to receive the medical care required in the comfort of their own home.
• Accurately document observations, interventions, and evaluations pertaining to patient care management and services.
• Work 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 on home-based care services.
• Perform a comprehensive patient/family assessment 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 continuing support and coordination for patient/family following 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 care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
• 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 work with the community and provider networks to expand access to needed physical, psychological, social, and environmental services.
• Participate in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promote effective resource utilization.
• Collect and evaluate data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.

Benefits

• Employee Referral Bonuses
• Clinical CEUs
• Online LinkedIn Learning
• Generous paid time off and holidays
• Extensive health, dental, and lifestyle benefits that come with being part of the renowned Dartmouth Health system

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level