Continuing Care Liaison MSW, Full-time

Dartmouth Health•White River Junction, VT

12d

About The Position

The Continuing Care Liaison – MSW is an integral member of a multidisciplinary health care team, helping complex-care patients transition from an acute care setting to home and supporting continuity of care after the transition. The role partners with acute-care interdisciplinary teams to identify patient and family needs, develop transition plans, and coordinate with home-based care teams to support successful outcomes at home. The position is based in the Upper Valley and surrounding areas, within Dartmouth Health Home Care, which provides nursing, rehabilitation, hospice, and personal care services across more than 70 towns. The liaison provides information and education about home-based care, assesses patients and families, coordinates care across settings, advocates for patient needs, and helps address barriers to transitioning home. The role also contributes to an interdisciplinary care delivery system, evaluates outcomes and resource use, and documents patient-care observations, interventions, and evaluations. The job description notes that duties may be modified and other related duties may be assigned to meet organizational needs.

Requirements

Master of Social Work (MSW) required.
At least one year of experience in a health-related field required.
Valid driver’s license required.
Clean driving record required.
Current car insurance meeting minimum standards required.
BLS certification required within 90 days of hire.

Nice To Haves

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

Responsibilities

Partner with acute-care interdisciplinary teams to identify patient and family needs and develop plans for successful transitions from acute care to home.
Continue supporting and coordinating care for patients and families after the transition home, working with home-based interdisciplinary teams to help achieve health outcomes.
Provide skilled nursing, rehabilitative care, and medical social work as part of a multidisciplinary team delivering care in patients’ homes.
Accurately document observations, interventions, and evaluations related to patient care management and services.
Work with discharge planners and referring providers to identify high-risk patients and support seamless transitions to Dartmouth Health Home Care services.
Provide information and education to prospective patients and families about home-based care services.
Conduct comprehensive patient and family assessments and develop transition plans in collaboration with patients, families, and care partners.
Advocate for patient needs and negotiate complex systems to remove barriers to transitioning home.
Monitor patient transitions across and within care settings, including home, clinic, 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 use.
Collect and evaluate data and outcomes, including patient satisfaction, health and functional status, and resource utilization.
Perform other related duties as assigned to meet organizational needs.