Integration Specialist Transitions of Care

Sea Mar Community Health Centers•Olympia, WA

3d•Hybrid

About The Position

Sea Mar Community Health Centers is seeking an Integration Specialist for Transitions of Care (TOC) to provide time-limited services ensuring healthcare continuity and preventing negative outcomes for at-risk populations. This role focuses on safe and timely patient transfers between care levels, offering advocacy and education during transitions from hospitals and other facilities to home. The specialist collaborates with hospital staff, discharge planners, and care facilities to resolve care gaps, improve clinical outcomes, and prevent readmissions and overuse of hospital services. Key support areas include medication self-management, patient use of personal health records (MyChart), and primary care/specialist follow-up, with an emphasis on patient understanding of "red flags" indicating worsening conditions. The position requires an understanding of diverse medical, mental health, and social determinant of health challenges, with interventions being time and scope limited. Staff are expected to conduct outreach and transition activities for all identified patients willing to participate and engage in community-wide efforts for improved interdisciplinary care.

Requirements

Ability to work effectively with all persons and groups with respect and an awareness of cultural differences.
Good organizational and communication skills.
Demonstrate professionalism and appropriate boundaries in all interactions.
No history or evidence of alcohol or other drug misuse for a period of three (3) years prior to the date of employment at the facility, and no misuse of alcohol or other drugs while employed at this facility.
Cannot be a person who has been convicted of a felony within the last seven years or ever been convicted of assault, abuse, fraud, or crimes that have brought harm to another financially, emotionally, or physically.
Ability to connect and maintain effective relationships and professional rapport with patients and other members of the care team; individual has strong communication skills.
Ability to act professionally in patient’s home setting, community setting, or clinic.
Ability to navigate different systems in relation to managing patients care transition needs
Ability to understand medical terminology pertaining to chronic conditions.
Ability to work with an interdisciplinary care team including medical providers, nursing staff, care coordinators, behavioral health and support staff.
Ability to perform independently and at the same time perform effectively and professionally as an interdisciplinary team member.
Ability to complete documentation in a timely and thorough manner.
Bilingual (Spanish/English) preferred.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before patients or employees of the organization.
Typing proficiency of at least 45 wpm.
Demonstratable computer skills and an ability to learn computer applications from manuals and webinars with minimal supervision.
Working knowledge of Microsoft Office.
Ability to learn and proficiently use programs as may pertain to use of electronic health records.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
Ability to apply critical thinking skills to carry out instructions furnished in written, oral or diagram form.
Ability to deal with problems involving several concrete variables in standardized situations.
BSW or BA/BS in Human Services, Health Sciences or related field with experience either in social service case management, or care coordination.
Experience working with underserved, transient populations.
Experience working with substance use disorders, chronic mental illness, and chronic health conditions.
Experience working with community agencies and has strong knowledge of community resources.
Pre-hire and annual health screening required.
Annual influenza vaccine required.
Must be fully vaccinated for COVID and provide documentation or an approved exemption as a condition of hire.
Will obtain CPR certification within initial probationary period and will maintain CPR certification throughout employment.
Must have a valid driver’s license and proof of auto insurance.

Nice To Haves

Experience with motivational interviewing, the teach-back method, or patient counseling and education preferred.

Responsibilities

Support for patient self-management by enhancing health literacy, assessing baseline comprehension, values, and goals, and engaging family/caregivers to be active participants in the patient’s care.
Systematically provide education and supportive interventions to increase patient’s skills and confidence in managing their health problems, goal setting, and problem-solving.
Advocate and negotiate to secure appropriate patient services.
Support and empower patients to make informed decisions, and to navigate the healthcare system to access appropriate care.
Build strong relationships with providers and discharge planners to maximize patient outcomes during periods of transition.
Assess readiness to learn, learning styles, and use the teach-back method for care interventions.
Use planned learning experiences to provide patients/families/caregivers opportunities to acquire the information and skills needed to make quality health decisions.
Use of effective communication skills to gain and transmit information, encourage team participation, leverage electronic medical record tools, and design/implement processes to provide timely and successful patient transitions of care.
Coaching and counseling of patients and family/caregivers regarding community resources, how to be prepared for “Ask Me Three”, and how to recognize red flags for complications.
Use of the case management process to develop care plans, provide medication reconciliation with the assistance of the TOC RNs, and use evidence-based practice for interventions.
Use of population health management tools to track and monitor select population characteristics and provide evidence-based practice interventions for select health populations.
Implement and evaluate interventions in the context of the health status, culture, and health needs of the populations of which the patient is a member.
Use of teamwork and interdisciplinary collaboration, open communication, and shared decision making with stakeholders.
Patient-centered care planning to include motivational interviewing and other techniques to elicit patient’s health care goals and priorities, individualizing care plan to transcend barriers and enhance patient outcomes.
Conducts outreach to all patients appropriate for Transitions of Care Services within two business days post discharge from hospital.
Ideally, connect with the patient and discharge planner/relevant hospital team in-person in the hospital prior to discharge.
Conducts most future contacts over the phone, except where we might visit the patient at home, meet them in the office, or attend PCP appointments with them.
Complete one discharge call to the patient within 48 business hours (or 2 attempts).
Completes at least three attempts to contact all patients appropriate for Transitions of Care Services within eight business days post discharge from hospital.
Contact includes speaking to a patient, their responsible party (family or caregiver), hospital, or other party (as agreed to by the patient).
Provides at least one weekly contact / contact attempt with each patient for the 3 weeks following (30 days).
Successful contacts include patient contacts, family/caregiver contacts, patient’s Sea Mar care team, and hospital contacts.
A successful contact means that the TOC Integration Specialist has spoken directly to a contact and has communicated information regarding the patient.
Collateral contacts throughout/as needed with other providers, and/or the patient’s family/caregivers.
Documents on all activities performed with patients within 24 hours.
Files will be audited on a regular basis to ensure compliance with Sea Mar and TOC policy.
Completes monthly reports detailing caseloads, statistics, and outcomes.