COMMUNITY OUTREACH LIAISON

Job Description Summary

Under the direction of the Community Outreach Manager, evaluates and prioritizes “At-Risk” patients at South Shore Hospital and community healthcare facilities identified as requesting home care services from the South Shore Visiting Nurse Association, Hospice of the South Shore, and Home and Health Resources. Provides discharge planning and care coordination to facilitate successful implementation of home care services. Works as a liaison between home care, hospital and the community to facilitate the continuum of care.

Job Description

Essential Functions

1. Identifies and prioritizes “At Risk” patients who have requested home care services from SSVNA, Hospice of the South Shore, or Home and Health Resources
a. Reviews list of patients admitted to SSH who are known to SSVNA, or who have requested SSVNA .

b. Evaluates potential “At Risk” patient situations that impact the discharge planning process.

c. “At Risk” patient situations may include, but are not limited to the following:
Home safety management
Limited or lack of available family support systems
Acute or complex medical /psychosocial problems

d. Identifies and prioritizes patients at community health care facilities who have requested home care services from SSVNA, Hospice of the South Shore or Home and Health Resources.

e. Develops working relationships in the community and acts as a "point person" for organizations when a patient has identified home care services from SSVNA, Hospice of the south Shore or Home and health Resources.

f. Works closely with physicians and physician practices to provide education regarding home care services available to patients in the community. Acts as a "point person" or liaison to facilitate referrals from physicians to home care services as requested.

g. Works collaboratively in the community with many other health care providers to provide education regarding home care services thru the South Shore VNA, Home and Health Resources and Hospice of the South Shore.


2. Assesses identified patients to determine home care needs, resources and care goals.

a. Meets with patients and explains liaison role.

b. Reviews health assessment data from medical record.

c. Initiates and participates in case conferences with care manager, physician, home care manager, direct provider staff, and others as indicated.

d. Recommends equipment, teaching or procedures that may be required to facilitate smooth transition to home care setting.

e. When indicated, shares previous home care plan of care, and level of home care services with SSH care manager or care manager assigned at the health care facility.

f. Documents assessment and recommendations in medical record, or other resource as indicated by the health care facility.

g. Obtains information on all insurance coverage guidelines and shares with staff.

h. Identifies and coordinates all discharge planning goals with SSH care manager, facility case manager and appropriate home care manager.


3. Coordinates with appropriate VNA , Hospice , and SSH staff regarding the potential discharge plan for At-Risk patients

a. Establishes and maintains working relationships with physicians, social workers, care managers and health plan case managers

b. Works collaboratively with interdisciplinary staff internal and external to organization , including Central Intake, home care managers, as well as direct care providers to develop appropriate home care plan of care

c. Provides education to hospital staff and other health care providers regarding home care programs , resources, and eligibility requirements as indicated

d. Acts as consultant to SSH care managers/SSH staff regarding home care programs, community resources, and alternative care settings.


4. Provides supporting documentation at time of referral to home care that reflects care and treatment , and requested home care services.

a. Completes appropriate referral forms according to SSH and home care policies and procedures and relays information to Central Intake.

b. Provides current information regarding patient clinical status and anticipated home care goals.


5. Technology – Embraces technological solutions to work processes and practices.

a. Demonstrates proficiency and competency specific to assigned Meditech and PtCT Modules.

b. Utilizes information systems and telecommunication services as instructed, this includes phones, mail boxes, pagers and email, wireless phones and paging applications as assigned.

c. Possesses base understanding of the appropriate use of various clinical equipment, e.g., IV pumps, enteral pumps, ventilators and their safe utilization in the home environment.

6. Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment

a. Understands individual roles/responsibilities during emergency situations (ex. Fire drill, electrical blackout, etc.)

b. Adheres to patient identification policies/practices

c. Uses personal protective equipment appropriately

d. Adheres to respiratory etiquette guidelines

e. Works with patients and families to ensure safe transitions from facilities to home setting

f. Utilizes proper body mecahnics when performing all aspects of job

Essential Functions (Cont.)

I. Technology and Learning

a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

NON-ESSENTIAL FUNCTIONS

Non-essential functions are those tasks, duties and responsibilities that are not critical to the performance of the job. Following are non-essential functions of the job, along with the corresponding performance standards.

1. Other duties as required

SKILLS Excellent verbal and written communication skills Critical thinking Creative Problem Solving Interdisciplinary collaboration Ability to prioritize and manage time effectively Conflict negotiation skills KNOWLEDGE Knowledge of home care eligibility criteria and reimbursement regulations Knowledge of VNA policies and procedures Working knowledge of varied health care insurance plans Strong Community resources Organizational skills
Bachelor of Science Degree preferred.
Minimum Work Experience
Requires two (2) years health care experience.