Senior Continuing Care Coordinator

Overview

St. Johns Riverside Hospital is a leader in providing the highest quality compassionate health care utilizing the latest state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson Ardsley Dobbs Ferry and Irvington St. Johns Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.

St. Johns has been an integral part of the community since the 1890s and its commitment to provide the community with the most advanced medical services available continues to be the hospitals vision mission and value. St. Johns Riverside Hospital built itself around an early foundation of nursing and community 1894 the Cochran School of Nursing the oldest hospital-based school of nursing in the metropolitan area was founded thus making the St. Johns Nursing Staff more than just the backbone of the hospital but the heart and soul. St. Johns dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.

St. Johns Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. Johns Riverside Hospital to their care.

St. Johns Riverside Hospital is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race creed color national origin sex age disability marital status or other legally protected classification in accordance with applicable federal state and local law.

Personalized care together with advanced technology is what it means to be Community Strong

Responsibilities

Responsible for participating in the development and education of new departmental employees. Responsibilities include but are not limited to educating new employees on the vision mission function theoretical framework and goals of the department. Ensuring the new employees understand departmental polices and procedures for a successful transition to independence in work performance post orientation.

Perform monthly staff meeting prep agenda and deliverables. Maintains staff meeting attendance logs and ensures the team attend educational staff meetings.

Manages and leads bed board meeting daily. Collects and shares information with designated department staff.

Assists in meeting the psychosocial needs of patients and families through assessment of inpatients based on assignment. Patients are screened for continuing care needs. The Continuing Care Coordinator educates coordinates and collaborates with nurses physicians case managers and interdisciplinary members of the Healthcare team to assure an ongoing comprehensive discharge plan.

Ensures appropriate use of resources within an appropriate length of stay. Collaborates with the multidisciplinary team on the patients treatment plan.

Reviews admissions and continued stays in accordance with establishing discharge plan.

Provides supervision and guidance to Continuing Care Coordinator staff to assist with difficult discharge and psychosocial situations.

Elevates staff performance issues and monitors employee tasks for compliance

Under the immediate supervision of the Director of Social Work a successful employee must demonstrate competency in the following areas:

Completes Psychosocial assessments within three days of patients admission including the ICU. The CCC through assessment and reassessment (every 4 days) will collaborate coordinate document and manage the discharge planning needs of the patients assigned. They will review cases for quality of care and utilization management issues and escalate those that are not resolved. The CCC will be consulted to provide supportive care and referrals for patients with terminal diagnosis difficulty coping and caretaker fatigue. Patients in Maternity and ER will be assessed through consults and screened for high-risk criteria such as substance use disorder abuse and other social determinates of health issues.

Informs patients and caretakers regarding admission criteria and referral process to the below services and follows through on these referrals to ensure a safe and timely discharge plan.

Visiting Nurse Services

Inpatient Skilled Nursing Care and Acute Rehabilitation

Long Term Home Care

Wound Care with VNS

Hospice Referrals

Ordering of Durable Medical Equipment

Other community resources as needed

Counsels and supports patients and their caretakers in relation to anxieties and stress precipitated by illness and hospitalization difficulty in coping with residual disability fears related to helplessness loss of capabilities and death.

Collaborates with community resources to develop a discharge plan and facilitate continuity of care. Maintains an update-to-date resource file and follows referral procedures to extended available services to meet patient needs. This includes private pay referrals for services not covered by their insurance carrier.

Utilizes assessment skills to determine:

Patients discharge planning goals

Health Care Proxy and Caretakers discharge concerns

Need for institutional and/or specialized care

Multi-disciplinary teams plan of care including (primary care physician primary care nurse continuing care coordinator physical therapist visiting nurse speech pathologist dietician)

Incorporates into an appropriate discharge plan for the patient

Assists in obtaining MD order and insurance authorization for the patients post hospital needs i.e. (but not limited to):

Certified Home Health Agency

Inpatient Skilled Nursing Care and Acute Rehabilitation

Home Hospice

Infusion therapy wound care

Medical supplies and equipment

Transportation

Assisting with burial of a patient which may include obtaining community/County resources contact with clergy and other family members.

Provide coverage for Dobbs Ferry to do pre assessment facilitate Joint Class order equipment for patients admitted through Same Day Surgery preparing for total joint replacement. CM is also assigned to the Ambulatory Services Unit for discharge planning needs when consulted.

Collaborates closely with hospital benefits area in identifying change of benefit status or lack of insurance.

Assists with complex discharge planning: proactively assess and manage the discharge planning needs for patients with complex medical psychosocial and resource challenges (e.g. homeless elderly with no family support lack of financial resources abuse/neglect cases complex end-of-life planning).

Participates in the performance improvement activities of the department by monitoring length of stay and timely documentation.

Escalates cases regarding quality of care and utilization issues to appropriate administrator.

Policy and process improvement: identify systemic issues participate in department/hospital committees and recommend improvements to continuing care processes policies and resource utilization to enhance quality of care and reduce hospital readmissions.

Responsible for the daily schedule and ensuring there is adequate coverage.

Orient the newly hired employees and completes required performance checklist.

Provides performance enhancing trainings and education to the department

Guides peers who are pursuing their LCSW on the completion of NYS application and submission for licensure.

Assist the departmental director in creating the monthly staff meeting agenda presenting the deliverables and maintaining the staff meeting attendance.

Assist in the interviewing of potential new departmental candidates.

Assumes other responsibilities when assigned.

Qualifications

New York State Screen assessment certification desirable.

Able to read write speak and understand the English language. Ability to communicate Spanish or community dominant language is an asset.

Effective professional rapport with physicians patient family/visitor peers and

supervisors. Sensitivity and Compassion.

Knowledge of the services of the community health welfare and social agencies.

Demonstrates flexibility and creativity. Must be able to function well under pressure. Must have good leadership ability and good judgment. Must have good mental and physical health.

Must be educated in the use of the particulate respirator (mask).

Masters degree required with at least 3 years discharge planning or Case Management experience. NYS license required LCSW

Required Experience:

Senior IC