Transitional Care Associate

Primary City/State:

Mesa, Arizona

Department Name:

Case Mgmt-Hosp

Work Shift:

Day

Job Category:

Clinical Care

Banner Baywood Medical Center is a 342 bed hospital serving the health care needs of the dynamic and growing East Valley communities of metropolitan Phoenix, Arizona. We provide complete acute care services and outpatient services to include but not limited to cancer, stroke, women's health, rehabilitation, emergency medicine and surgery. Our Emergency Department treats a variety of ailments and offers advanced treatment areas, with 68 beds, seeing over 50,000 patients per year. We are certified as pediatric prepared  as well as designated as a Trauma level 3 emergency room. In addition, our comprehensive orthopedic unit is one of the nation’s premier orthopedic programs. The unit's commitment to excellent patient care has earned a 4 STAR rating by CMS and repeated recognition as having one of the Top 100 Orthopedic Programs in the U.S. by The Health Network and HCIA, Inc. Because we are also a leader in neurological medicine, people throughout Arizona come to us when they need treatment for conditions of the brain, spine and nervous system.

POSITION SUMMARY
This position facilitates the safe and timely transition of clients from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care or community program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides on-site or telephonic discharge arrangements to post-acute and community services.

CORE FUNCTIONS
1. Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting. Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.

2. Facilitates/ implements the care plan with proposed interventions in collaboration with healthcare team. Collaborates with all members of the healthcare team to implement, manage and communicate the transition of care arrangements.

3. Participates in performance improvement projects, Banner initiatives and performs data collection for measurement of projects as assigned.

4. Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.

5. Assist and support patients and families in making appropriate arrangements for the post-acute plan. Performs follow-up calls to patients and providers as indicated and report any concerns to leadership.

6. Serves as an intermediary when providing community resources to patients, caregiver, and families. Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipated discharge date and potential care settings.

7. Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.

8. Employee has freedom to determine how to best accomplish functions within established procedures and implements the discharge plan under the delegated authority of a provider, licensed MSW, registered nurse or other licensed healthcare professional. Confers with supervisor/manager on any unusual situations and communicates plans and activities for patient discharge across the care continuum. Internal customers: Post-acute services team members and all levels of nursing management and staff, medical staff, and all other members of assigned facility interdisciplinary health care team. External customers: home health agencies, nursing homes, insurance providers, group homes, assisted living facilities, hospice, long-term acute care hospitals, inpatient rehabilitation facilities, volunteer agencies, county/governmental agencies and medical supply companies and others as required.

MINIMUM QUALIFICATIONS
A Bachelor’s degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.

Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid, long term care or other applicable resources/services. Must demonstrate effective communication and customer service skills, human relation skills and time management skills. Must be able to work flexible hours and work weekends on rotation. BLS required. (BLS is not required for employees working in the Insurance Division.)

Employees working at Banner Behavioral Health Hospital, BTMC Behavioral, and BUMG, BUMCT, or BUMCS in a Behavioral Health clinical setting that serves children must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. An Arizona Criminal History Affidavit must be signed upon hire.

PREFERRED QUALIFICATIONS

Previous experience in health care service setting, interacting with patients and families, usually obtained through work in social services, as a licensed practical nurse or in a discharge planning setting.

Additional related education and/or experience preferred.

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