Care Coordinator, Social Worker I - REACH Team - Orlando Health Bayfront Hospital

Site: Orlando Health Bayfront Hospital

Location: St. Petersburg, Florida 

Department: Corporate Care Management/REACH Team

Shift/Status: PRN/Pool - 2 to 3 days per week

REACH, which stands for REadmission Advocates Collaborating in Healthcare, is an Orlando Health program that provides an extension of care management for patients after they are discharged from the hospital. REACH helps to connect a patient/family with community resources, referrals and other services that can help make managing healthcare easier and enhance quality of life. REACH services are available at all Orlando Health hospitals.

The Social Worker I collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and preventative care services.

Essential Functions

• Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency and ambulatory care/ outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
• Develops an effective working relationship with the Care Management Team to engage the patient/family to collaborate, advocate and problem solve, to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan.
• Daily monitoring of progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family needs with a priority placed on those patients at highest risk for complication/ admission/ readmission.
• Educates patients/ families with chronic illness about evidence-based standards of care to include self-management strategies.
• Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies.
• Educates patients and families about the health care system and facilitates relationship building between the various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals and revising the care plan as indicated.
• Advocates for patients in order to optimize their health care needs including but not limited to: safety, physical, legal and financial well-being.
• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
• Works with available IT resources (i.e. Allscripts Care Management, EMR, etc.) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement to include the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions to include the implementation of policies, procedures and standards to support the assigned duties.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
• Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span.
• Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.

Education/Training

• Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.

Licensure/Certification

• BLS

Experience

• One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship in healthcare.